The BURP manoeuvre for better glottic view using the paediatric GlideScope

Evaluation of different airway tests to determine difficult intubation in apparently normal adult patients: undergoing surgical procedures

Background

Inadequate maintenance of a patient’s airway represents a major cause of anesthesia-related morbidity and mortality. This study was designed to evaluate common preoperative clinical tests to determine the risk of difficult endotracheal intubation in apparent “normal” adult patients undergoing surgical procedures.

Methods

A prospective observational cohort study was performed on 160 consecutive adult patients undergoing surgical procedures at an academic medical center in Jordan from 20 May 2019 until 11 February 2020.

Preoperative assessment of airway risk stratification was performed by the following clinical tests: the mandible protrusion test (MPT), thyromental (TMD) and sternomental (SMD) distances, inter-incisor gap (IIG), and the modified Mallampati tests with tongue protrusion (MMT-TP) and without tongue protrusion (MMT-NTP). Grade C on the MPT, TMD ≤ 6 cm, SMD ≤ 12 cm, and MMT grades III and IV were considered to be predictors of difficult endotracheal intubations. A modified Cormack-Lehane grading (MCLG) of laryngoscopic views with backward, upward, and right-sided pressure on the thyroid and cricoid cartilages (BURP) maneuver was also documented, with grades 2B, 3, and 4 considered to be difficult airways for intubation.

Results

Fifteen patients (9.4%) were classified as MCLG 2B, 3, and 4, with age significantly associated with the MCLG grade (P = 0.028). The sensitivity and Youden’s index of MMT-TP were found to be the lowest (40% and 0.29, respectively). The MPT was the most accurate and specific test (90.63 and 95.17%, respectively), with the highest PPV (50%), Youden’s index (0.42), and area under the curve (AUC) (0.781). Bivariant analysis of MPT and the t-test of the mean TMDs and SMDs revealed significant associations between these airway tests and the difficulty of intubation (P values: < 0.001, 0.02, < 0.01, respectively).

Conclusion

The MPT, with its highest accuracy, specificity, positive predictive value, and good sensitivity may be used as a routine screening test for preoperative prediction of difficult endotracheal intubations.

[Glottiscopes and videolaryngoscopes: a rational choice?]

Different airway devices can be used by paediatrician anaesthesiologists for difficult airway management in infant younger than 2 years. The four devices analyzed (Airtraq® [Prodol Meditec]; Glidescope® Cobalt [Verathon]; Vidéolaryngoscope [Storz]; laryngoscope Truview® [Truphatek]) increase the Cormack and Lehane grade against direct laryngoscopy and optimized external larynx movements. They need training, on manikin then in vivo, for an optimal use. The needed number of in vivo successful intubations is not determined. It is probably between 10 and 20. The choice between these devices, in accordance with the published studies, which compared the devices, is difficult. The manikin studies allow to standardize airway, but the results are not transposable in vivo. Concerning the airway devices with disposable blade, the Glidescope®, for oral intubation, seems to be better than Airtraq® if we take into account the oropharyngeal volume needed.

A comparison of the BURP and conventional and modified jaw thrust manoeuvres for orotracheal intubation using the Clarus Video System

We evaluated the effects of three airway manipulation manoeuvres: (a) conventional (single-handed chin lift); (b) backward, upward and right-sided pressure (BURP) manoeuvre; and (c) modified jaw thrust manoeuvre (two-handed aided by an assistant) on laryngeal view and intubation time using the Clarus Video System in 215 patients undergoing general anaesthesia with orotracheal intubation. In the first part of this study, the laryngeal view was recorded as a modified Cormack-Lehane grade with each manoeuvre. In the second part, intubation was performed using the assigned airway manipulation. The primary outcome was the time to intubation, and the secondary outcomes were the modified Cormack-Lehane grade, the number of attempts and the overall success rate. There were significant differences in modified Cormack-Lehane grade between the three airway manipulations (p < 0.0001). Post-hoc analysis indicated that the modified jaw thrust improved the laryngeal view compared with the conventional (p < 0.0001) and the BURP manoeuvres (p < 0.0001). The BURP worsened the laryngeal view compared with the conventional manoeuvre (p = 0.0132). The time to intubation in the modified jaw thrust group was shorter than with the conventional manoeuvre (p = 0.0004) and the BURP group (p < 0.0001). We conclude that the modified jaw thrust is the most effective manoeuvre at improving the laryngeal view and shortening intubation time with the Clarus Video System.

Critical airway skills and procedures

Airway management is a critical procedure and essential skill necessary for all physicians working in the emergency department. Optimal resuscitative treatment of medical and trauma patients often revolves around timely and effective airway interventions that can be challenging in the acute setting, especially in critical patients. Time-honored airway techniques and procedures combined with recent advances in rapid sequence intubation, video laryngoscopy, and further advanced airway techniques now offer emergency clinicians a wide range of exciting new options for improving this crucial component of acute care and management.