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Taboada M, Estany-Gestal A, Rial M, Cariñena A, Martínez A, Selas S, Eiras M, Veiras S, Ferreiroa E, Cardalda B, López C, Calvo A, Fernández J, Álvarez J, Alcántara JM, Seoane-Pillado T. Impact of Universal Use of the McGrath Videolaryngoscope as a Device for All Intubations in the Cardiac Operating Room. A Prospective Before-After VIDEOLAR-CAR Study. J Cardiothorac Vasc Anesth 2024; 38:1499-1505. [PMID: 38580479 DOI: 10.1053/j.jvca.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 03/02/2024] [Accepted: 03/11/2024] [Indexed: 04/07/2024]
Abstract
OBJECTIVE Tracheal intubation in cardiac surgery patients has a higher incidence of difficult laryngoscopic views compared with patients undergoing other types of surgery. The authors hypothesized that using the McGrath Mac videolaryngoscope as the first intubation option for cardiac surgery patients improves the percentage of patients with "easy intubation" compared with using a direct Macintosh laryngoscope. DESIGN A prospective, observational, before-after study. SETTING At a tertiary-care hospital. PARTICIPANTS One thousand one hundred nine patients undergoing cardiac surgery. INTERVENTION Consecutive patients undergoing cardiac surgery were intubated using, as the first option, a Macintosh laryngoscope (preinterventional phase) or a McGrath Mac videolaryngoscope (interventional phase). MEASUREMENTS AND MAIN RESULTS The main objective was to assess whether the use of the McGrath videolaryngoscope, as the first intubation option, improves the percentage of patients with "easy intubation," defined as successful intubation on the first attempt, modified Cormack-Lehane grades of I or IIa, and the absence of the need for adjuvant airway devices. A total of 1,109 patients were included, 801 in the noninterventional phase and 308 in the interventional phase. The incidence of "easy intubation" was 93% in the interventional phase versus 78% in the noninterventional phase (p < 0.001). First-success-rate intubation was higher in the interventional phase (304/308; 98.7%) compared with the noninterventional phase (754/801, 94.1%; p = 0.005). Intubation in the interventional phase showed decreases in the incidence of difficult laryngoscopy (12/308 [3.9%] v 157/801 [19.6%]; p < 0.001), as well as moderate or difficult intubation (5/308 [1.6%] v 57/801 [7.1%]; p < 0.001). CONCLUSIONS The use of the McGrath videolaryngoscope as the first intubation option for tracheal intubation in cardiac surgery improves the percentage of patients with "easy" intubation," increasing glottic view and first-success-rate intubation and decreasing the incidence of moderate or difficult intubation.
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Affiliation(s)
- Manuel Taboada
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain.
| | - Ana Estany-Gestal
- Research Methodology Unit. Fundación Instituto de Investigaciones Sanitarias (FIDIS), Santiago, Spain
| | - María Rial
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Agustín Cariñena
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Adrián Martínez
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Salomé Selas
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - María Eiras
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Sonia Veiras
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Esteban Ferreiroa
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Borja Cardalda
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Carmen López
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Andrea Calvo
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Jorge Fernández
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Julián Álvarez
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Jorge Miguel Alcántara
- Research Methodology Unit. Fundación Instituto de Investigaciones Sanitarias (FIDIS), Santiago, Spain
| | - Teresa Seoane-Pillado
- Preventive Medicine and Public Health Unit, Department of Health Sciences, University of A Coruña-INIBIC, A Coruña, Spain
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Ardak Z TL, Arslan ZP, Cesur S, Aksu B. Comparison of haemodynamic response to tracheal intubation with two different videolaryngoscopes: A randomized clinical trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2023; 73:548-555. [PMID: 34384793 PMCID: PMC10533975 DOI: 10.1016/j.bjane.2021.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/13/2021] [Accepted: 07/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Endotracheal intubation (ETI), which is the gold standard in coronary artery bypass grafting (CABG), may cause myocardial ischaemia by disturbing the balance between haemodynamic changes and oxygen supply and consumption of the myocardium as a result of sympathetic stimulation. In this study, we aimed to compare two different videolaryngoscopes (C-MAC and Airtraq) in the hemodynamic response to ETI. METHODS Fifty ASA II...III CABG surgery patients were randomly assigned to C-MAC or Airtraq. The hemodynamic data included arterial blood pressure [systolic (SAP), diastolic (DAP) and mean (MAP)] and heart rate (HR) and were recorded at six different points in time: before laryngoscopy-T1, during laryngoscopy-T2, immediately after intubation-T3, and 3 (T4), 5 (T5) and 10 (T6) minutes after intubation. Intraoperative complications were recorded. Patients were questioned about postoperative complications 2 and 24...hours following extubation. RESULTS The hemodynamic response to ETI was significantly greater with C-MAC. The increase in HR started with the laryngoscopy procedure, whereas increases in SAP, DAP, and MAP started immediately after ETI (p...=...0.024; p...=...0.012; p...=...0.030; p...=...0.009, respectively). In group analyses, T1...T2, T2...T3 and T1...T3 comparisons did not show any significant differences in HR with Airtraq. However, with C-MAC, HR after intubation increased significantly compared to the pre-laryngoscopy values (T1...T3) (p...=...0.004). The duration of laryngoscopy was significantly reduced with C-MAC (p...<...0.001), but the duration of intubation and total intubation were similar (p...=...0.36; p...=...0.79). CONCLUSIONS Compared to C-MAC, the hemodynamic response to ETI was less with Airtraq. Thus, Airtraq may be preferred in CABG patients for ETI.
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Affiliation(s)
- T Lay Ardak Z
- Kocaeli University of Medical Faculty, Department of Anesthesiology and Reanimation, ..zmit, Turkey.
| | - Z Pek Arslan
- Kocaeli University of Medical Faculty, Department of Anesthesiology and Reanimation, ..zmit, Turkey
| | - Sevim Cesur
- Kocaeli University of Medical Faculty, Department of Anesthesiology and Reanimation, ..zmit, Turkey
| | - Bar Aksu
- Kocaeli University of Kand..ra Vocational School, ..zmit, Turkey
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Jayaraj AK, Siddiqui N, Abdelghany SMO, Balki M. Management of difficult and failed intubation in the general surgical population: a historical cohort study in a tertiary care centre. Can J Anaesth 2022; 69:427-437. [PMID: 34907502 DOI: 10.1007/s12630-021-02161-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 11/03/2021] [Accepted: 11/06/2021] [Indexed: 12/19/2022] Open
Abstract
PURPOSE The objective of this study was to describe the incidence, management, and complications of difficult and failed endotracheal intubation in a general surgical population. METHODS This historical cohort study included all cases of difficult endotracheal intubation in general surgical patients at Mount Sinai Hospital (Toronto, ON, Canada) from 1 January 2011 to 31 December 2017. Patient charts and electronic records were reviewed to collect data on airway management and complications. Endotracheal intubation was graded as "difficult" if more than two attempts with direct laryngoscopy or if additional equipment for second or subsequent attempts was required, and "failed" if it could not be achieved despite the attempts. The primary outcome was the incidence of difficult and failed intubation. The secondary outcomes were complications, difficult airway parameters, mask ventilation, number of intubation attempts, and rescue devices including the eventually successful method. RESULTS We identified 111 cases of difficult intubation (0.26%) and 14 cases of failed intubation (0.03%) in 42,805 surgical cases requiring endotracheal intubation over the seven-year period. The incidence was highest in 2012 (0.36%) and lowest in 2017 (0.13%). Difficulty was anticipated in 84 (76%) patients. The median (range) number of intubation attempts was 2 (2-5). Videolaryngoscopy was the eventually successful method in those with unsuccessful first attempt direct laryngoscopy (n = 91) and videolaryngoscopy (n = 17) in 71% and 77% cases, respectively. Intubation failed in 14 patients, three of whom required a surgical airway because the lungs could not be ventilated. Poor visualization of the glottis (93%) and airway bleeding (36%) were the leading causes of failed intubation. Desaturation was seen in 8%, airway bleeding in 7%, and airway edema in 6% of cases of difficult intubation. CONCLUSION The incidences of difficult and failed intubations in our study were 2.6 and 0.3 per 1,000 surgeries requiring laryngoscopies, respectively, with a decrease over time. Videolaryngoscopy showed a high success rate as a rescue device.
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Affiliation(s)
- Ashok Kumar Jayaraj
- Advanced Airway Management, Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Naveed Siddiqui
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Mrinalini Balki
- Department of Anesthesiology and Pain Medicine, Department of Obstetrics & Gynaecology, and Department of Physiology, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Room 7-405, Toronto, ON, M5G 1X5, Canada.
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada.
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Optimization of Intraoperative Neural Monitoring of the Recurrent Laryngeal Nerve in Thyroid Surgery. Medicina (B Aires) 2022; 58:medicina58040495. [PMID: 35454334 PMCID: PMC9028259 DOI: 10.3390/medicina58040495] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/18/2022] [Accepted: 03/25/2022] [Indexed: 11/17/2022] Open
Abstract
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.
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Schnittker R, Marshall S, Berecki‐Gisolf J. Patient and surgery factors associated with the incidence of failed and difficult intubation. Anaesthesia 2020; 75:756-766. [DOI: 10.1111/anae.14997] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2019] [Indexed: 11/30/2022]
Affiliation(s)
- R. Schnittker
- Monash University Accident Research Centre Melbourne Vic. Australia
| | - S.D. Marshall
- Department of Anaesthesia and Peri‐operative Medicine Monash University Melbourne Vic. Australia
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Affiliation(s)
- T Ezri
- Kaplan Medical Center, Rehovot, Israel
| | - A Dukhan
- Kaplan Medical Center, Rehovot, Israel
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Roth D, Herkner H, Lee A. Reply to bedside predictors of difficult airway - neck mobility. Anaesthesia 2019; 74:1617. [PMID: 31681992 DOI: 10.1111/anae.14836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- D Roth
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - H Herkner
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - A Lee
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong
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Roth D, Pace NL, Lee A, Hovhannisyan K, Warenits AM, Arrich J, Herkner H. Bedside tests for predicting difficult airways: an abridged Cochrane diagnostic test accuracy systematic review. Anaesthesia 2019; 74:915-928. [DOI: 10.1111/anae.14608] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2019] [Indexed: 12/13/2022]
Affiliation(s)
- D. Roth
- Emergency Medicine Medical University of Vienna Austria
| | - N. L. Pace
- Department of Anesthesiology University of Utah Salt Lake City UT USA
| | - A. Lee
- Department of Anaesthesia and Intensive Care The Chinese University of Hong Kong Shatin Hong Kong
- Hong Kong Branch of The Chinese Cochrane Centre The Jockey Club School of Public Health and Primary Care The Chinese University of Hong Kong Shatin Hong Kong
| | - K. Hovhannisyan
- Clinical Health Promotion Centre Faculty of Medicine Lund University MalmöSweden
| | - A. M. Warenits
- Department of Emergency Medicine Medical University of Vienna Austria
| | - J. Arrich
- Department of Emergency Medicine Medical University of Vienna Austria
| | - H. Herkner
- Department of Emergency Medicine Medical University of Vienna Austria
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Detsky ME, Jivraj N, Adhikari NK, Friedrich JO, Pinto R, Simel DL, Wijeysundera DN, Scales DC. Will This Patient Be Difficult to Intubate?: The Rational Clinical Examination Systematic Review. JAMA 2019; 321:493-503. [PMID: 30721300 DOI: 10.1001/jama.2018.21413] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Recognizing patients in whom endotracheal intubation is likely to be difficult can help alert physicians to the need for assistance from a clinician with airway training and having advanced airway management equipment available. OBJECTIVE To identify risk factors and physical findings that predict difficult intubation. DATA SOURCES The databases of MEDLINE and EMBASE were searched from 1946 to June 2018 and from 1947 to June 2018, respectively, and the reference lists from the retrieved articles and previous reviews were searched for additional studies. STUDY SELECTION Sixty-two studies with high (level 1-3) methodological quality that evaluated the accuracy of clinical findings for identifying difficult intubation were reviewed. DATA EXTRACTION AND SYNTHESIS Two authors independently abstracted data. Bivariate random-effects meta-analyses were used to calculate summary positive likelihood ratios across studies or univariate random-effects models when bivariate models failed to converge. RESULTS Among the 62 high-quality studies involving 33 559 patients, 10% (95% CI, 8.2%-12%) of patients were difficult to intubate. The physical examination findings that best predicted a difficult intubation included a grade of class 3 on the upper lip bite test (lower incisors cannot extend to reach the upper lip; positive likelihood ratio, 14 [95% CI, 8.9-22]; specificity, 0.96 [95% CI, 0.93-0.97]), shorter hyomental distance (range of <3-5.5 cm; positive likelihood ratio, 6.4 [95% CI, 4.1-10]; specificity, 0.97 [95% CI, 0.94-0.98]), retrognathia (mandible measuring <9 cm from the angle of the jaw to the tip of the chin or subjectively short; positive likelihood ratio, 6.0 [95% CI, 3.1-11]; specificity, 0.98 [95% CI, 0.90-1.0]), and a combination of physical findings based on the Wilson score (positive likelihood ratio, 9.1 [95% CI, 5.1-16]; specificity, 0.95 [95% CI, 0.90-0.98]). The widely used modified Mallampati score (≥3) had a positive likelihood ratio of 4.1 (95% CI, 3.0-5.6; specificity, 0.87 [95% CI, 0.81-0.91]). CONCLUSIONS AND RELEVANCE Although several simple clinical findings are useful for predicting a higher likelihood of difficult endotracheal intubation, no clinical finding reliably excludes a difficult intubation. An abnormal upper lip bite test, which is easily assessed by clinicians, raises the probability of difficult intubation from 10% to greater than 60% for the average-risk patient.
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Affiliation(s)
- Michael E Detsky
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Naheed Jivraj
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Neill K Adhikari
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jan O Friedrich
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Departments of Critical Care Medicine and Medicine, St Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - David L Simel
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Duminda N Wijeysundera
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Comparison of hemodynamic responses to endotracheal intubation with the GlideScope video laryngoscope and Macintosh laryngoscope in patients undergoing cardiovascular surgery. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2018; 26:386-393. [PMID: 32082768 DOI: 10.5606/tgkdc.dergisi.2018.15716] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 04/23/2018] [Indexed: 12/12/2022]
Abstract
Background This study aimed to compare hemodynamic response to endotracheal intubation using GlideScope and Macintosh laryngoscopes in patients who underwent cardiovascular surgery. Methods A total of 74 patients were enrolled in the study. Patients were randomly assigned into two groups either a GlideScope (n=37) or a Macintosh laryngoscope (n=37). Laryngoscopy time, heart rate, invasive arterial pressure and rate pressure product were compared during induction and until five minutes after laryngoscopy at 11 time points. Results Seventy patients completed the study. The intubation time was similar in both groups (14.1±4.0 sec vs. 13.2±4.2 sec; p=0.22). Hemodynamic values including heart rate, systolic, diastolic and mean arterial pressure and rate pressure product were similar at all-time points. The laryngoscopy time was also similar between groups. Conclusion The GlideScope video laryngoscope did not show any advantage on hemodynamic response in patients undergoing cardiovascular surgery when compared to Macintosh laryngoscope.
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Roth D, Pace NL, Lee A, Hovhannisyan K, Warenits A, Arrich J, Herkner H. Airway physical examination tests for detection of difficult airway management in apparently normal adult patients. Cochrane Database Syst Rev 2018; 5:CD008874. [PMID: 29761867 PMCID: PMC6404686 DOI: 10.1002/14651858.cd008874.pub2] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The unanticipated difficult airway is a potentially life-threatening event during anaesthesia or acute conditions. An unsuccessfully managed upper airway is associated with serious morbidity and mortality. Several bedside screening tests are used in clinical practice to identify those at high risk of difficult airway. Their accuracy and benefit however, remains unclear. OBJECTIVES The objective of this review was to characterize and compare the diagnostic accuracy of the Mallampati classification and other commonly used airway examination tests for assessing the physical status of the airway in adult patients with no apparent anatomical airway abnormalities. We performed this individually for each of the four descriptors of the difficult airway: difficult face mask ventilation, difficult laryngoscopy, difficult tracheal intubation, and failed intubation. SEARCH METHODS We searched major electronic databases including CENTRAL, MEDLINE, Embase, ISI Web of Science, CINAHL, as well as regional, subject specific, and dissertation and theses databases from inception to 16 December 2016, without language restrictions. In addition, we searched the Science Citation Index and checked the references of all the relevant studies. We also handsearched selected journals, conference proceedings, and relevant guidelines. We updated this search in March 2018, but we have not yet incorporated these results. SELECTION CRITERIA We considered full-text diagnostic test accuracy studies of any individual index test, or a combination of tests, against a reference standard. Participants were adults without obvious airway abnormalities, who were having laryngoscopy performed with a standard laryngoscope and the trachea intubated with a standard tracheal tube. Index tests included the Mallampati test, modified Mallampati test, Wilson risk score, thyromental distance, sternomental distance, mouth opening test, upper lip bite test, or any combination of these. The target condition was difficult airway, with one of the following reference standards: difficult face mask ventilation, difficult laryngoscopy, difficult tracheal intubation, and failed intubation. DATA COLLECTION AND ANALYSIS We performed screening and selection of the studies, data extraction and assessment of methodological quality (using QUADAS-2) independently and in duplicate. We designed a Microsoft Access database for data collection and used Review Manager 5 and R for data analysis. For each index test and each reference standard, we assessed sensitivity and specificity. We produced forest plots and summary receiver operating characteristic (ROC) plots to summarize the data. Where possible, we performed meta-analyses to calculate pooled estimates and compare test accuracy indirectly using bivariate models. We investigated heterogeneity and performed sensitivity analyses. MAIN RESULTS We included 133 (127 cohort type and 6 case-control) studies involving 844,206 participants. We evaluated a total of seven different prespecified index tests in the 133 studies, as well as 69 non-prespecified, and 32 combinations. For the prespecified index tests, we found six studies for the Mallampati test, 105 for the modified Mallampati test, six for the Wilson risk score, 52 for thyromental distance, 18 for sternomental distance, 34 for the mouth opening test, and 30 for the upper lip bite test. Difficult face mask ventilation was the reference standard in seven studies, difficult laryngoscopy in 92 studies, difficult tracheal intubation in 50 studies, and failed intubation in two studies. Across all studies, we judged the risk of bias to be variable for the different domains; we mostly observed low risk of bias for patient selection, flow and timing, and unclear risk of bias for reference standard and index test. Applicability concerns were generally low for all domains. For difficult laryngoscopy, the summary sensitivity ranged from 0.22 (95% confidence interval (CI) 0.13 to 0.33; mouth opening test) to 0.67 (95% CI 0.45 to 0.83; upper lip bite test) and the summary specificity ranged from 0.80 (95% CI 0.74 to 0.85; modified Mallampati test) to 0.95 (95% CI 0.88 to 0.98; Wilson risk score). The upper lip bite test for diagnosing difficult laryngoscopy provided the highest sensitivity compared to the other tests (P < 0.001). For difficult tracheal intubation, summary sensitivity ranged from 0.24 (95% CI 0.12 to 0.43; thyromental distance) to 0.51 (95% CI 0.40 to 0.61; modified Mallampati test) and the summary specificity ranged from 0.87 (95% CI 0.82 to 0.91; modified Mallampati test) to 0.93 (0.87 to 0.96; mouth opening test). The modified Mallampati test had the highest sensitivity for diagnosing difficult tracheal intubation compared to the other tests (P < 0.001). For difficult face mask ventilation, we could only estimate summary sensitivity (0.17, 95% CI 0.06 to 0.39) and specificity (0.90, 95% CI 0.81 to 0.95) for the modified Mallampati test. AUTHORS' CONCLUSIONS Bedside airway examination tests, for assessing the physical status of the airway in adults with no apparent anatomical airway abnormalities, are designed as screening tests. Screening tests are expected to have high sensitivities. We found that all investigated index tests had relatively low sensitivities with high variability. In contrast, specificities were consistently and markedly higher than sensitivities across all tests. The standard bedside airway examination tests should be interpreted with caution, as they do not appear to be good screening tests. Among the tests we examined, the upper lip bite test showed the most favourable diagnostic test accuracy properties. Given the paucity of available data, future research is needed to develop tests with high sensitivities to make them useful, and to consider their use for screening difficult face mask ventilation and failed intubation. The 27 studies in 'Studies awaiting classification' may alter the conclusions of the review, once we have assessed them.
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Affiliation(s)
- Dominik Roth
- Medical University of ViennaDepartment of Emergency MedicineWähringer Gürtel 18‐20ViennaAustriaA‐1090
| | - Nathan L Pace
- University of UtahDepartment of Anesthesiology3C444 SOM30 North 1900 EastSalt Lake CityUTUSA84132‐2304
| | - Anna Lee
- The Chinese University of Hong KongDepartment of Anaesthesia and Intensive CarePrince of Wales HospitalShatinNew TerritoriesHong Kong
- The Chinese University of Hong KongHong Kong Branch of The Chinese Cochrane Centre, The Jockey Club School of Public Health and Primary Care, Faculty of MedicineShatinNew TerritoriesHong Kong
| | - Karen Hovhannisyan
- Lund UniversityClinical Health Promotion Centre, Faculty of MedicineSkånes Universitetssjukhus, Södra Förstadsgatan 35, Plan 4MalmöSwedenS‐205 02
| | - Alexandra‐Maria Warenits
- Medical University of ViennaDepartment of Emergency MedicineWähringer Gürtel 18‐20ViennaAustriaA‐1090
| | - Jasmin Arrich
- Medical University of ViennaDepartment of Emergency MedicineWähringer Gürtel 18‐20ViennaAustriaA‐1090
| | - Harald Herkner
- Medical University of ViennaDepartment of Emergency MedicineWähringer Gürtel 18‐20ViennaAustriaA‐1090
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Jain N, Das S, Kanchi M. Thyromental height test for prediction of difficult laryngoscopy in patients undergoing coronary artery bypass graft surgical procedure. Ann Card Anaesth 2017; 20:207-211. [PMID: 28393782 PMCID: PMC5408527 DOI: 10.4103/aca.aca_229_16] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Patients undergoing coronary artery bypass graft (CABG) procedures have higher incidence of difficult laryngoscopy and intubation than general surgery population. Accurate prediction of difficult laryngoscopy in CABG patients is desirable to reduce the hemodynamic response and myocardial oxygen requirements. Recently, thyromental height test (TMHT) has been proposed as one of the highly sensitive and specific bedside tests to predict difficult airway. We, in our prospective observational study, evaluated the accuracy of the TMHT in predicting difficult laryngoscopy. METHODOLOGY A total of 345 patients undergoing CABG of either sex, in the age group of 35-80 years, American Society of Anesthesiologists 111, undergoing CABG, were studied. Airway assessment was performed with modified Mallampati test with the addition of thyromental distance, sternomental distance, and TMHT. Intraoperatively, direct laryngoscopy was done in accordance with Cormack and Lehane grade of laryngoscopy. The preoperative data and laryngoscopic findings were used together to evaluate the accuracy of TMHT. The sensitivity, specificity, positive and negative predictive values of other three tests were calculated according to standard formula. RESULTS A total of 345 patients were in the group with mean age of study population at 56.7 (standard deviation 9.1) years (35-80 years). This study showed that almost all tests had good specificity, but sensitivity was poor. However, sensitivity of TMHT was 75% with accuracy of 95%. Receiver operating characteristic curve analysis of TMHT-derived cutoff was 52.17 which increased sensitivity to 81.25% and specificity to 92.3%. CONCLUSION TMHT had a higher sensitivity compared to other tests along with good positive and negative predictive value and a very high specificity.
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Affiliation(s)
- Nilesh Jain
- Department of Cardiac Anaesthesia and Critical Care, Narayana Hrudayalaya, Bengaluru, Karnataka, India
| | - Sucharita Das
- Department of Cardiac Anaesthesia and Critical Care, Narayana Hrudayalaya, Bengaluru, Karnataka, India
| | - Muralidhar Kanchi
- Department of Cardiac Anaesthesia and Critical Care, Narayana Hrudayalaya, Bengaluru, Karnataka, India
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Borde DP, Futane SS, Daunde V, Zine S, Joshi N, Jaiswal S, Chinchole S, Kulkarni P, Hiwarkar A, Bhagyawant P, Deshmukh D, Takalkar M. Are cardiac surgical patients at increased risk of difficult intubation? Indian J Anaesth 2017; 61:629-635. [PMID: 28890557 PMCID: PMC5579852 DOI: 10.4103/ija.ija_283_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background and Aims: Safe airway management is the cornerstone of contemporary anaesthesia practice, and difficult intubation (DI) remains a major cause of anaesthetic morbidity and mortality. The surgical category, particularly cardiac surgery as a risk factor for DI has not been studied extensively. The aim of this study was to test the hypothesis whether cardiac surgical patients are at increased risk of DI. Methods: During the study, 627 patients (329 cardiac and 298 non-cardiac surgical) were enrolled. Pre-operative demographic and other variables associated with DI were assessed. Patients with Cormack Lehane grade III and IV or use of bougie in Cormack grade II were defined as DI. The incidence of anticipated and unanticipated DI was assessed. Factors associated with DI were described using univariate and multivariate logistic regression models. Results: The overall incidence of DI was 122/627 (19.46%). The incidence of DI was higher in cardiac surgery patients (24%) as compared to non-cardiac surgery patients (14.4% P = 0.002). On multivariate analysis, factors independently associated with DI were greater age, male sex, higher Mallampati grade, and anticipated DI, but not cardiac surgery. The incidence of unanticipated DI was 48.1% and 53.4% in cardiac and non-cardiac surgery patients, respectively. Conclusion: Although there was a higher incidence of DI in cardiac surgical patients, cardiac surgery is not an independent risk factor for DI. Rather, other factors play more important role. About half of the DI both in cardiac and non-cardiac surgeries were unanticipated.
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Affiliation(s)
- Deepak Prakash Borde
- Department of Anaesthesia, Ozone Anaesthesia Group, United CIIGMA Hospital, Aurangabad, Maharashtra, India
| | - Savani Sameer Futane
- Department of Anaesthesia, Ozone Anaesthesia Group, United CIIGMA Hospital, Aurangabad, Maharashtra, India
| | - Vijay Daunde
- Department of Anaesthesia, Ozone Anaesthesia Group, United CIIGMA Hospital, Aurangabad, Maharashtra, India
| | - Sujata Zine
- Department of Anaesthesia, Ozone Anaesthesia Group, United CIIGMA Hospital, Aurangabad, Maharashtra, India
| | - Nayana Joshi
- Department of Anaesthesia, Ozone Anaesthesia Group, United CIIGMA Hospital, Aurangabad, Maharashtra, India
| | - Sumit Jaiswal
- Department of Anaesthesia, Ozone Anaesthesia Group, United CIIGMA Hospital, Aurangabad, Maharashtra, India
| | - Sadhana Chinchole
- Department of Anaesthesia, Ozone Anaesthesia Group, United CIIGMA Hospital, Aurangabad, Maharashtra, India
| | - Prasannakumar Kulkarni
- Department of Anaesthesia, Ozone Anaesthesia Group, United CIIGMA Hospital, Aurangabad, Maharashtra, India
| | - Amit Hiwarkar
- Department of Anaesthesia, Ozone Anaesthesia Group, United CIIGMA Hospital, Aurangabad, Maharashtra, India
| | - Priti Bhagyawant
- Department of Anaesthesia, Ozone Anaesthesia Group, United CIIGMA Hospital, Aurangabad, Maharashtra, India
| | - Dilip Deshmukh
- Department of Anaesthesia, Ozone Anaesthesia Group, United CIIGMA Hospital, Aurangabad, Maharashtra, India
| | - Manisha Takalkar
- Department of Anaesthesia, United CIIGMA Hospital, Aurangabad, Maharashtra, India
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Heinrich S, Ackermann A, Prottengeier J, Castellanos I, Schmidt J, Schüttler J. Increased Rate of Poor Laryngoscopic Views in Patients Scheduled for Cardiac Surgery Versus Patients Scheduled for General Surgery: A Propensity Score-Based Analysis of 21,561 Cases. J Cardiothorac Vasc Anesth 2015; 29:1537-43. [DOI: 10.1053/j.jvca.2015.04.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Indexed: 11/11/2022]
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Peirovifar A, Mahmoodpoor A, Golzari SE, Soleimanpour H, Eslampour Y, Fattahi V. Efficacy of video-guided laryngoscope in airway management skills of medical students. J Anaesthesiol Clin Pharmacol 2014; 30:488-91. [PMID: 25425772 PMCID: PMC4234783 DOI: 10.4103/0970-9185.142810] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background & Aims: Video-guided laryngoscopy, though unproven in achieving better success rates of laryngoscopy outcome and intubation, seems to provide better glottic visualization compared with direct laryngoscopy. The objective of this study was to compare the efficacy of video-guided laryngoscope (VGL) in the airway management skills of medical students. Materials and Methods: Medical students throughout their anesthesiology rotations were enrolled in this study. All students received standard training in the airway management during their course and were randomly allocated into two 20 person groups. In Group D, airway management was performed by direct laryngoscopy via Macintosh blade and in Group G intubation was performed via VGL. Time to intubation, number of laryngoscopy attempts and success rate were noted. Successful intubation was considered as the primary outcome. Statistical Analysis: All data were analyzed using SPSS 16 software. Chi-square and Fisher's exact test were used for analysis of categorical variables. For analyzing continuous variables independent t-test was used. P < 0.05 was considered as statistically significant. Results: Number of laryngoscopy attempts was less in Group G in comparison to Group D; this, however, was statistically insignificant (P: 0.18). Time to intubation was significantly less in Group G as compared to Group D (P: 0.02). Successful intubation in Group G was less frequently when compared to Group D (P: 0.66). Need for attending intervention, esophageal intubation and hypoxemic events during laryngoscopy were less in Group G; this, however, was statistically insignificant. Conclusions: The use of video-guided laryngoscopy improved the first attempt success rate, time to intubation, laryngoscopy attempts and airway management ability of medical students compared to direct laryngoscopy.
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Affiliation(s)
- Ali Peirovifar
- Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ata Mahmoodpoor
- Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Samad Ej Golzari
- Liver and Gastrointestinal Disease Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Hassan Soleimanpour
- Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Yashar Eslampour
- Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Vahid Fattahi
- Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
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Heinrich S, Birkholz T, Irouschek A, Ackermann A, Schmidt J. Incidences and predictors of difficult laryngoscopy in adult patients undergoing general anesthesia : a single-center analysis of 102,305 cases. J Anesth 2013; 27:815-21. [PMID: 23748552 DOI: 10.1007/s00540-013-1650-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 05/27/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hypoxemia caused by difficulties in airway management presents a major cause for perioperative morbidity and mortality. The ability to predict difficult laryngoscopy more accurately would enable anesthesiologists to take specific precautions to reduce airway risks and prevent patient-threatening events. METHODS Over a 6-year period of time, all anesthesia records with a documented direct laryngoscopic view were retrieved from the electronic data management system and statistically processed. The Cormack-Lehane four-point scale of grading laryngoscopy was used to assess visibility of the vocal cords. RESULTS Of 102,306 cases, the overall rate of difficult laryngoscopy was 4.9 %. Male gender (6.5 %), Mallampati score III and IV (17.3 %), obesity with a BMI ≥35 kg/m(2) (6.1 %), as well as physical status ASA III or IV (6.2 %), were identified as risk factors for difficult laryngoscopy. Patients undergoing surgery in the departments of oromaxillofacial (8.9 %), ear nose throat surgery (ENT) (7.4 %), and cardiac surgery (7.0 %) showed the highest rates of difficult laryngoscopy. CONCLUSIONS The results indicate that the risk for difficult airway situations might substantially differ between surgical patient groups. In hospitals with departmental structures and spatially separated operating rooms, the deduction might be increased awareness and particular structural preparation for difficult airway situations in the respective subspecialties.
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Affiliation(s)
- S Heinrich
- Department of Anesthesia, University Hospital Erlangen, Krankenhausstrasse 12, 91054, Erlangen, Germany,
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Griesdale DEG, Liu D, McKinney J, Choi PT. Glidescope® video-laryngoscopy versus direct laryngoscopy for endotracheal intubation: a systematic review and meta-analysis. Can J Anaesth 2011; 59:41-52. [PMID: 22042705 PMCID: PMC3246588 DOI: 10.1007/s12630-011-9620-5] [Citation(s) in RCA: 236] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 10/19/2011] [Indexed: 02/07/2023] Open
Abstract
Introduction The Glidescope® video-laryngoscopy appears to provide better glottic visualization than direct laryngoscopy. However, it remains unclear if it translates into increased success with intubation. Methods We systematically searched electronic databases, conference abstracts, and article references. We included trials in humans comparing Glidescope® video-laryngoscopy to direct laryngoscopy regarding the glottic view, successful first-attempt intubation, and time to intubation. We generated pooled risk ratios or weighted mean differences across studies. Meta-regression was used to explore heterogeneity based on operator expertise and intubation difficulty. Results We included 17 trials with a total of 1,998 patients. The pooled relative risk (RR) of grade 1 laryngoscopy (vs ≥ grade 2) for the Glidescope® was 2.0 [95% confidence interval (CI) 1.5 to 2.5]. Significant heterogeneity was partially explained by intubation difficulty using meta-regression analysis (P = 0.003). The pooled RR for nondifficult intubations of grade 1 laryngoscopy (vs ≥ grade 2) was 1.5 (95% CI 1.2 to 1.9), and for difficult intubations it was 3.5 (95% CI 2.3 to 5.5). There was no difference between the Glidescope® and the direct laryngoscope regarding successful first-attempt intubation or time to intubation, although there was significant heterogeneity in both of these outcomes. In the two studies examining nonexperts, successful first-attempt intubation (RR 1.8, 95% CI 1.4 to 2.4) and time to intubation (weighted mean difference −43 sec, 95% CI −72 to −14 sec) were improved using the Glidescope®. These benefits were not seen with experts. Conclusion Compared to direct laryngoscopy, Glidescope® video-laryngoscopy is associated with improved glottic visualization, particularly in patients with potential or simulated difficult airways.
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Affiliation(s)
- Donald E G Griesdale
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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Lundstrøm LH, Vester-Andersen M, Møller AM, Charuluxananan S, L'hermite J, Wetterslev J. Poor prognostic value of the modified Mallampati score: a meta-analysis involving 177 088 patients. Br J Anaesth 2011; 107:659-67. [PMID: 21948956 DOI: 10.1093/bja/aer292] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The modified Mallampati score is used to predict difficult tracheal intubation. We have conducted a meta-analysis of published studies to evaluate the Mallampati score as a prognostic test. A total of 55 studies involving 177 088 patients were included after comprehensive electronic and manual searches. The pooled estimates from the meta-analyses were calculated based on a random-effects model and a summary receiver operating curve. Meta-regression analyses were performed to explore sources of possible heterogeneity between the studies. The summary receiver operating curve demonstrated an area under the curve of 0.75. The pooled odds ratio for a difficult intubation with a modified Mallampati score of III or IV was 5.89 [95% confidence interval (CI), 4.74-7.32]. The pooled estimates of the specificity and sensitivity were 0.91 (CI, 0.91-0.91) and 0.35 (CI, 0.34-0.36), respectively. The pooled positive and negative likelihood ratios were 4.13 (CI, 3.60-4.66) and 0.70 (CI, 0.65-0.75), respectively. The meta-analyses had statistical and clinical heterogeneity ranging from 87.2% to 99.4%. Meta-regression analyses did not identify any significant explanation of the heterogeneity. We conclude that the prognostic value of the modified Mallampati score was worse than that estimated by previous meta-analyses. Our assessment shows that the modified Mallampati score is inadequate as a stand-alone test of a difficult laryngoscopy or tracheal intubation, but it may well be a part of a multivariate model for the prediction of a difficult tracheal intubation.
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Affiliation(s)
- L H Lundstrøm
- Department of Anaesthesia and Intensive Care, Herlev Hospital, Copenhagen University Hospital, Herlev, Denmark
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Griesdale DEG, Henderson WR, Green RS. Airway management in critically ill patients. Lung 2011; 189:181-92. [PMID: 21274550 DOI: 10.1007/s00408-011-9278-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2010] [Accepted: 01/10/2011] [Indexed: 12/19/2022]
Abstract
In critically ill patients, endotracheal intubation is associated with a high risk of complications, including severe hypoxemia and hypotension. The purpose of this review is to discuss the definitions, complications, airway assessment, and patient optimization with respect to these patients. In addition, we present different approaches and techniques to help secure the airway in critically ill patients. We also discuss strategies to help minimize the risk of a difficult or failed airway and to mitigate the severe life-threatening complications associated with this high-risk procedure.
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Affiliation(s)
- Donald E G Griesdale
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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Abstract
INTRODUCTION The difficult airway is a common problem in adult critical care patients. However, the challenge is not just the establishment of a safe airway, but also maintaining that safety over days, weeks, or longer. AIMS This review considers the management of the difficult airway in the adult critical care environment. Central themes are the recognition of the potentially difficult airway and the necessary preparation for (and management of) difficult intubation and extubation. Problems associated with tracheostomy tubes and tube displacement are also discussed. RESULTS All patients in critical care should initially be viewed as having a potentially difficult airway. They also have less physiological reserve than patients undergoing airway interventions in association with elective surgery. Making the critical care environment as conducive to difficult airway management as the operating room requires planning and teamwork. Extubation of the difficult airway should always be viewed as a potentially difficult reintubation. Tube displacement or obstruction should be strongly suspected in situations of new-onset difficult ventilation. CONCLUSIONS Critical care physicians are presented with a significant number of difficult airway problems both during the insertion and removal of the airway. Critical care physicians need to be familiar with the difficult airway algorithms and have skill with relevant airway adjuncts.
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Lavery G, Jamison C. Airway Management in the Critically Ill Adult. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50004-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lee A, Fan LTY, Gin T, Karmakar MK, Ngan Kee WD. A Systematic Review (Meta-Analysis) of the Accuracy of the Mallampati Tests to Predict the Difficult Airway. Anesth Analg 2006; 102:1867-78. [PMID: 16717341 DOI: 10.1213/01.ane.0000217211.12232.55] [Citation(s) in RCA: 155] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The original and modified Mallampati tests are commonly used to predict the difficult airway, but there is controversy regarding their accuracy. We searched MEDLINE and other databases for prospective studies of patients undergoing general anesthesia in which the results of a preoperative Mallampati test were compared with the subsequent rate of difficult airway (difficult laryngoscopy, difficult intubation, or difficult ventilation as reference tests). Forty-two studies enrolling 34,513 patients were included. The definitions of the reference tests varied widely. For predicting difficult laryngoscopy, both versions of the Mallampati test had good accuracy (area under the summary receiver operating characteristic (sROC) curve = 0.89 +/- 0.05 and 0.78 +/- 0.05, respectively). For predicting difficult intubation, the modified Mallampati test had good accuracy (area under the sROC curve = 0.83 +/- 0.03) whereas the original Mallampati test was poor (area under the sROC curve = 0.58 +/- 0.12). The Mallampati tests were poor at identifying difficult mask ventilation. Publication bias was not detected. Used alone, the Mallampati tests have limited accuracy for predicting the difficult airway and thus are not useful screening tests.
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Affiliation(s)
- Anna Lee
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong.
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Stürmer T, Joshi M, Glynn RJ, Avorn J, Rothman KJ, Schneeweiss S. A review of the application of propensity score methods yielded increasing use, advantages in specific settings, but not substantially different estimates compared with conventional multivariable methods. J Clin Epidemiol 2006; 59:437-47. [PMID: 16632131 PMCID: PMC1448214 DOI: 10.1016/j.jclinepi.2005.07.004] [Citation(s) in RCA: 466] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2005] [Accepted: 06/15/2005] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Propensity score (PS) analyses attempt to control for confounding in nonexperimental studies by adjusting for the likelihood that a given patient is exposed. Such analyses have been proposed to address confounding by indication, but there is little empirical evidence that they achieve better control than conventional multivariate outcome modeling. STUDY DESIGN AND METHODS Using PubMed and Science Citation Index, we assessed the use of propensity scores over time and critically evaluated studies published through 2003. RESULTS Use of propensity scores increased from a total of 8 reports before 1998 to 71 in 2003. Most of the 177 published studies abstracted assessed medications (N=60) or surgical interventions (N=51), mainly in cardiology and cardiac surgery (N=90). Whether PS methods or conventional outcome models were used to control for confounding had little effect on results in those studies in which such comparison was possible. Only 9 of 69 studies (13%) had an effect estimate that differed by more than 20% from that obtained with a conventional outcome model in all PS analyses presented. CONCLUSIONS Publication of results based on propensity score methods has increased dramatically, but there is little evidence that these methods yield substantially different estimates compared with conventional multivariable methods.
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Affiliation(s)
- Til Stürmer
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA 02120, USA.
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