Video and optic laryngoscopy assisted tracheal intubation--the new era

The Clinical Usability Evaluation of an Attachable Video Laryngoscope in the Simulated Tracheal Intubation Scenario: A Manikin Study

The aim of this study was to assess the usefulness of an attachable video laryngoscope (AVL) by attaching a camera and a monitor to a conventional Macintosh laryngoscope (CML). Normal and tongue edema airway scenarios were simulated using a manikin. Twenty physicians performed tracheal intubations using CML, AVL, Pentax Airwayscope® (AWS), and McGrath MAC® (MAC) in each scenario. Ten physicians who had clinical experience in using tracheal intubation were designated as the skilled group, and another ten physicians who were affiliated with other departments and had little clinical experience using tracheal intubation were designated as the unskilled group. The time required for intubation and the success rate were recorded. The degree of difficulty of use and glottic view assessment were scored by participants. All 20 participants successfully completed the study. There was no difference in tracheal intubation success rate and intubation time in the normal airway scenario in both skilled and unskilled groups. In the experienced group, AWS had the highest success rate (100%) in the tongue edema airway scenario, followed by AVL (60%), MAC (60%), and CML (10%) (p = 0.001). The time required to intubate using AWS was significantly shorter than that with AVL (10.2 s vs. 19.2 s) or MAC (10.2 s vs. 20.4 s, p = 0.007). The difficulty of using AVL was significantly lower than that of CML (7.8 vs. 2.8; p < 0.001). For the experienced group, AVL was interpreted as being inferior to AWS but better than MAC. Similarly, in the unskilled group, AVL had a similar success rate and tracheal intubation time as MAC in the tongue edema scenario, but this was not statistically significant. The difficulty of using AVL was significantly lower than that of CML (8.8 vs. 3.3; p < 0.001). AVL may be an alternative for VL.

Market Analysis of Video Laryngoscopy Equipment for the Role 1 Setting

INTRODUCTION

Airway compromise is the second leading cause of potentially preventable prehospital combat death. Endotracheal intubation (ETI) remains the most common role 1 airway intervention. Video laryngoscopy (VL) is superior to direct laryngoscopy (DL) for first-attempt intubation, especially in less-experienced providers and for trauma patients. The cost has been a major challenge in pushing VL technology far-forward; however, the cost of equipment continues to become more affordable. We conducted a market analysis of VL devices under $10,000 for possible options for role 1.

MATERIALS AND METHODS

We searched Google, PubMed, and the Food and Drug Administration database from August 2022 to January 2023 with a combination of several keywords to identify current VL market options under $10,000. After identifying relevant manufacturers, we then reviewed individual manufacturer or distributor websites for pricing data and system specifications. We noted several characteristics regarding VL device design for comparison. These include monitor features, size, modularity, system durability, battery life, and reusability. When necessary, we requested formal price quotes from respective companies.

RESULTS

We identified 17 VL options under $10,000 available for purchase, 14 of which were priced below $5,000 for individual units. Infium (n = 3) and Vimed Medical (n = 4) provided the largest number of unique models. VL options under $10,000 exist in both reusable and disposable modalities. These modalities included separate monitors as well as monitors attached to the VL handle. Disposable options, on a per-unit basis, cost less than reusable options.

CONCLUSIONS

Several VL options exist within our goal price point in both reusable and disposable options. Clinical studies assessing the technology performance of ETI and deliberate downselection are needed to identify the most cost-effective solution for role 1 dispersion.

Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates

BACKGROUND

Establishment of a secure airway is a critical part of neonatal resuscitation in the delivery room and the neonatal intensive care unit. Videolaryngoscopy has the potential to facilitate successful endotracheal intubation, and decrease adverse consequences of a delay in airway stabilization. Videolaryngoscopy may enhance visualization of the glottis and intubation success in neonates. This is an update of a review first published in 2015, and updated in 2018.

OBJECTIVES

To determine the effectiveness and safety of videolaryngoscopy compared to direct laryngoscopy in decreasing the time and attempts required for endotracheal intubation and increasing the success rate on first intubation attempt in neonates (0 to 28 days of age).

SEARCH METHODS

In November 2022, we updated the search for trials evaluating videolaryngoscopy for neonatal endotracheal intubation in CENTRAL, MEDLINE, Embase, CINAHL, and BIOSIS. We also searched abstracts of the Pediatric Academic Societies, clinical trials registries (www.

CLINICALTRIALS

gov; www.controlled-trials.com), and reference lists of relevant studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs), quasi-RCTs, cluster-RCTs, or cross-over trials, in neonates (0 to 28 days of age), evaluating videolaryngoscopy with any device used for endotracheal intubation compared with direct laryngoscopy.

DATA COLLECTION AND ANALYSIS

Three review authors performed data collection and analysis, as recommended by Cochrane Neonatal. Two review authors independently assessed studies identified by the search strategy for inclusion. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

The updated search yielded 7786 references, from which we identified five additional RCTs for inclusion, seven ongoing trials, and five studies awaiting classification. Three studies were included in the previous version of the review. For this update, we included eight studies, which provided data on 759 intubation attempts in neonates. We included neonates of either sex, who were undergoing endotracheal intubation in international hospitals. Different videolaryngoscopy devices (including C-MAC, Airtraq, and Glidescope) were used in the studies. For the primary outcomes; videolaryngoscopy may not reduce the time required for successful intubation when compared with direct laryngoscopy (mean difference [MD] 0.74, 95% confidence interval [CI] -0.19 to 1.67; 5 studies; 505 intubations; low-certainty evidence). Videolaryngoscopy may result in fewer intubation attempts (MD -0.08, 95% CI -0.15 to 0.00; 6 studies; 659 intubations; low-certainty evidence). Videolaryngoscopy may increase the success of intubation at the first attempt (risk ratio [RR] 1.24, 95% CI 1.13 to 1.37; risk difference [RD] 0.14, 95% CI 0.08 to 0.20; number needed to treat for an additional beneficial outcome [NNTB] 7, 95% CI 5 to 13; 8 studies; 759 intubation attempts; low-certainty evidence).  For the secondary outcomes; the evidence is very uncertain about the effect of videolaryngoscopy on desaturation or bradycardia episodes, or both, during intubation (RR 0.94, 95% CI 0.38 to 2.30; 3 studies; 343 intubations; very-low certainty evidence). Videolaryngoscopy may result in little to no difference in the lowest oxygen saturations during intubation compared with direct laryngoscopy (MD -0.76, 95% CI -5.74 to 4.23; 2 studies; 359 intubations; low-certainty evidence). Videolaryngoscopy likely results in a slight reduction in the incidence of airway trauma during intubation attempts compared with direct laryngoscopy (RR 0.21, 95% CI 0.05 to 0.79; RD -0.04, 95% CI -0.07 to -0.01; NNTB 25, 95% CI 14 to 100; 5 studies; 467 intubations; moderate-certainty evidence). There were no data available on other adverse effects of videolaryngoscopy. We found a high risk of bias in areas of allocation concealment and performance bias in the included studies.

AUTHORS' CONCLUSIONS

Videolaryngoscopy may increase the success of intubation on the first attempt and may result in fewer intubation attempts, but may not reduce the time required for successful intubation (low-certainty evidence). Videolaryngoscopy likely results in a reduced incidence of airway-related adverse effects (moderate-certainty evidence). These results suggest that videolaryngoscopy may be more effective and potentially reduce harm when compared to direct laryngoscopy for endotracheal intubation in neonates. Well-designed, adequately powered RCTS are necessary to confirm the efficacy and safety of videolaryngoscopy in neonatal intubation.

Videolaryngoscopy: a help or a hindrance?

Airway management is fundamental to anaesthesia, and technology may help with the safety of this procedure. Videolaryngoscopy is a developing area, which is becoming commonplace in anaesthesia practice.

Evolution of videolaryngoscopy in pediatric population

Direct laryngoscopy has remained the sole method for securing airway ever since the inception of endotracheal intubation. The recent introduction of video-laryngoscopes has brought a paradigm shift in the pratice of airway management. It is claimed that they improve the glottic view and first pass success rates in adult population. The airway management in children is more challenging than adults. The role of videolaryngoscopy for routine intubation in children is not clearly proven. This review attempts to discuss various videolaryngosocpes available for use in pediatric patients.

Comparison of the paediatric blade of the Pentax-AWS and Ovassapian airway in fibreoptic tracheal intubation in patients with limited mouth opening and cervical spine immobilization by a semi-rigid neck collar: a randomized controlled trial

Background

We compared the performances of the paediatric blade of a Pentax Airway Scope and an Ovassapian airway in fibreoptic tracheal intubation in patients whose necks were stabilized by semi-rigid neck collars.

Methods

Ninety patients were enrolled in this prospective, open-label, randomized controlled trial. Patients were randomly allocated to one of two groups (Group OVA-FOB and Group AWS-FOB). The time to tracheal intubation, success rate of tracheal intubation, number of optimization manoeuvres (jaw thrust), and difficulty of manipulation of the fibreoptic bronchoscope were compared between the groups.

Results

The time to tracheal intubation was significantly shorter (32 vs 50 s; median difference 19 s; 95% confidence interval 14-25 s; P<0.001) and manipulation of the fibreoptic bronchoscope was significantly easier for Group AWS-FOB. Optimization manoeuvres were rarely required to facilitate fibreoptic tracheal intubation in Group AWS-FOB [jaw thrust, 0 (0%); jaw thrust with anterior neck collar removal, 1 (2%)] compared with that required in Group OVA-FOB [jaw thrust, 39 (87%); jaw thrust with anterior neck collar removal, 2 (4%)]. There was no significant difference in the success rate of tracheal intubation on the first attempt between groups [Group AWS-FOB, 45 (100%); Group OVA-FOB, 44 (98%)].

Conclusions

Combined use of the paediatric blade of a Pentax Airway Scope and a fibreoptic bronchoscope enabled rapid tracheal intubation, minimizing the use of external manoeuvres of the airway, in patients with limited mouth opening and cervical spine immobilization by semi-rigid neck collars, compared with use of the Ovassapian airway and the fibreoptic bronchoscope.

Clinical trial registration

NCT02827110.

Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates

BACKGROUND

Establishment of a secure airway is a critical part of neonatal resuscitation in the delivery room and the neonatal unit. Videolaryngoscopy has the potential to facilitate successful endotracheal intubation and decrease adverse consequences of delay in airway stabilization. Videolaryngoscopy may enhance visualization of the glottis and intubation success in neonates.

OBJECTIVES

To determine the efficacy and safety of videolaryngoscopy compared to direct laryngoscopy in decreasing the time and attempts required for endotracheal intubation and increasing the success rate at first intubation in neonates.

SEARCH METHODS

We used the search strategy of Cochrane Neonatal. In May 2017, we searched for randomized controlled trials (RCT) evaluating videolaryngoscopy for neonatal endotracheal intubation in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, abstracts of the Pediatric Academic Societies, websites for registered trials at www.clinicaltrials.gov and www.controlled-trials.com, and reference lists of relevant studies.

SELECTION CRITERIA

RCTs or quasi-RCTs in neonates evaluating videolaryngoscopy for endotracheal intubation compared with direct laryngoscopy.

DATA COLLECTION AND ANALYSIS

Review authors performed data collection and analysis as recommended by Cochrane Neonatal. Two review authors independently assessed studies identified by the search strategy for inclusion.We used the GRADE approach to assess the quality of evidence.

MAIN RESULTS

The search yielded 7057 references of which we identified three RCTs for inclusion, four ongoing trials and one study awaiting classification. All three included RCTs compared videolaryngoscopy with direct laryngoscopy during intubation attempts by trainees.Time to intubation was similar between videolaryngoscopy and direct laryngoscopy (mean difference (MD) -0.62, 95% confidence interval (CI) -6.50 to 5.26; 2 studies; 311 intubations) (very low quality evidence). Videolaryngoscopy did not decrease the number of intubation attempts (MD -0.05, 95% CI -0.18 to 0.07; 2 studies; 427 intubations) (very low quality evidence). Moderate quality evidence suggested that videolaryngoscopy increased the success of intubation at first attempt (typical risk ratio (RR) 1.44, 95% CI 1.20 to 1.73; typical risk difference (RD) 0.19, 95% CI 0.10 to 0.28; number needed to treat for an additional beneficial outcome (NNTB) 5, 95% CI 4 to 10; 3 studies; 467 intubation attempts).Desaturation episodes during intubation attempts were similar between videolaryngoscopy and direct laryngoscopy (MD -0.76, 95% CI -5.74 to 4.23; 2 studies; 359 intubations) (low quality evidence). There was no difference in the incidence of airway trauma due to intubation attempts (RR 0.10, 95% CI 0.01 to 1.80; RD -0.04, 95% CI -0.09 to -0.00; 1 study; 213 intubations) (low quality evidence).There were no data available on other adverse effects of videolaryngoscopy.

AUTHORS' CONCLUSIONS

Moderate to very low quality evidence suggests that videolaryngoscopy increases the success of intubation in the first attempt but does not decrease the time to intubation or the number of attempts for intubation. However, these studies were conducted with trainees performing the intubations and these results highlight the potential usefulness of the videolaryngoscopy as a teaching tool. Well-designed, adequately powered RCTs are necessary to confirm efficacy and address safety and cost-effectiveness of videolaryngoscopy for endotracheal intubation in neonates by trainees and those proficient in direct laryngoscopy.

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.

Comparison of the McGrath videolaryngoscope and the Macintosh laryngoscope for double lumen endobronchial tube intubation in patients with manual in-line stabilization: A randomized controlled trial

BACKGROUND

Double lumen endobronchial tube (DLT) intubation is commonly used for one-lung ventilation in thoracic surgery. However, because of its large size and shape, it is difficult to perform intubation compared with a single lumen tube. The aim of this randomized controlled trial was to determine whether the McGrath videolaryngoscope has any advantage over the direct Macintosh laryngoscope for DLT intubation in patients with a simulated difficult airway.

METHODS

Forty-four patients (19-60 years of age); scheduled to undergo general anesthesia with one-lung ventilation were assigned to 1 of 2 groups: DLT intubation with the McGrath videolaryngoscope (ML group [n = 22]); or conventional Macintosh laryngoscope (DL group [n = 22]). After manual in-line stabilization was applied as a way of simulating a difficult airway, the time required for intubation and the quality of glottic view were evaluated.

RESULTS

The time to successful intubation was not different between the 2 groups (ML group, 45 s [interquartile range, 38-52 s] versus DL group, 54 s [45-59 s]; P = .089). The McGrath videolaryngoscope, however, provided a significantly better glottic view. Modified Cormack and Lehane grade was better (P < .001), and the percentage of glottis opening score was higher in the ML group (P < .001). Overall intubation difficulty scale score was lower in the ML group (1 [0-2]) versus the DL group (3 [2-4]) (P < .001).

CONCLUSION

The McGrath videolaryngoscope improved glottic view and resulted in lower overall intubation difficulty scale score in patients with in-line stabilization.

Ease of Intubation with C-MAC Videolaryngoscope: Use of 60° Angled Styletted Endotracheal Tube versus Intubation over Bougie

Background:

Although videolaryngoscopes improve glottic visualization, their actual usefulness in intubation is not yet established.

Aims:

The primary objective was to compare the ease of oral intubation with the use of 60° angled styletted endotracheal tube versus that performed over bougie inserted under videolaryngoscopic guidance. The secondary objectives were assessment of incidence of airway loss, hemodynamic changes, and time and number of attempts at intubation.

Settings and Design:

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

Patients and Methods:

Seventy surgical patients requiring oral intubation were randomly allotted to Group S or Group B. Laryngoscopy was performed with Storz^® C-MAC videolaryngoscope using D-Blade. In Group S, patients were intubated with a 60° angled stylletted endotracheal tube. In Group B, a bougie was introduced into the trachea and endotracheal tube was railroaded over the bougie.

Statistical Analysis Used:

Chi-square test and independent sample t-test were used as applicable.

Results:

The ease of intubation was significantly more in patients of Group S as compared to Group B (88.6% vs. 25.7%, respectively, P < 0.001) with significantly shorter intubation time (16.97 ± 7.91 vs. 77.43 ± 35.55 s, respectively, P < 0.001). The requirement of more than one attempt at intubation was significantly higher in Group B [57.1% vs. 5.7% P < 0.001, respectively]. Group B showed a significantly high mean arterial pressure at 1 and 3 min following intubation with no significant change in heart rate.

Conclusion:

Use of 60° angled styletted endotracheal tube resulted in easier and faster intubation as compared to intubation over a bougie when used with C-MAC videolaryngoscope.

Videolaryngoscopy in Neonates, Infants, and Children

Airway management is vital during anesthetic care and during resuscitative efforts in the PICU, the emergency department, and the delivery room. Given specific anatomic and physiologic differences, neonates and infants may be more prone to complications during airway management. Videolaryngoscopy may offer an alternative to or advantages over direct laryngoscopy in specific clinical scenarios. The following article reviews some of the basic types of videolaryngoscopy and discusses their potential applications in the pediatric population.

Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults

These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team.

The AirView Study: Comparison of Intubation Conditions and Ease between the Airtraq-AirView and the King Vision

We conducted a study assessing the quality and speed of intubation between the Airtraq with its new iPhone AirView app and the King Vision in a manikin. The primary endpoint was reduction of time needed for intubation. Secondary endpoints included times necessary for intubation. 30 anaesthetists randomly performed 3 intubations with each device on a difficult airway manikin. Participants had a professional experience of 12 years: 60.0% possessed the Airtraq in their hospital, 46.7% the King Vision, and 20.0% both. Median time difference [IQR] to identify glottis (1.1 [-1.3; 3.9] P = 0.019), for tube insertion (2.1 [-2.6; 9.4] P = 0.002) and lung ventilation (2.8 [-2.4; 11.5] P = 0.001), was shorter with the Airtraq-AirView. Median time for glottis visualization was significantly shorter with the Airtraq-AirView (5.3 [4.0; 8.4] versus 6.4 [4.6; 9.1]). Cormack Lehane before intubation was better with the King Vision (P = 0.03); no difference was noted during intubation, for subjective device insertion or quality of epiglottis visualisation. Assessment of tracheal tube insertion was better with the Airtraq-AirView. The Airtraq-AirView allows faster identification of the landmarks and intubation in a difficult airway manikin, while clinical relevance remains to be studied. Anaesthetists assessed the intubation better with the Airtraq-AirView.

Video rigid flexing laryngoscope (RIFL) vs Miller laryngoscope for tracheal intubation during pediatric resuscitation by paramedics: a simulation study

OBJECTIVES

Endotracheal intubation (ETI) is an essential resuscitation procedure in children. Video laryngoscopes have been developed to avoid intubation failures in a variety of scenarios, including cardiopulmonary resuscitation. We hypothesized that the video laryngoscope RIFL (AI Medical Devices, Inc, Williamston, MI) offers advantages in the ETI of a pediatric manikin while performing chest compressions (CCs).

METHODS

Randomized nonblinded crossover simulation trial conducted among 132 paramedics with no prior experience with RIFL. Each participant performed intubations with Miller (MIL; Mercury Medical, Clearwater, FL) laryngoscope and RIFL in a PediaSIM CPR training manikin (FCAE HealthCare, Sarasota, FL) in 3 airway scenarios: (a) normal airway at rest (without concomitant CC), (b) normal airway with mechanically controlled CC, and (c) difficult airway with concomitant CC. The primary outcome was the time to intubation, and secondary one was the success of the intubation attempt.

RESULTS

In the manikin at rest with normal airway, nearly all participants performed successful ETI both with MIL and RIFL, with similar intubation times. However, in the other scenarios (normal and difficult airway with uninterrupted CC), the results with RIFL were significantly better than with MIL (P < .05) for all the analyzed variables (success of first attempt, overall success rate, time to intubation, Cormac-Lehane grade, dental compression, and easy of intubation scores).

CONCLUSIONS

In simulated child arrest scenarios with normal/difficult airway conditions and with concomitant mechanical CC, paramedics performed better with the RIFL video laryngoscope than with the standard MIL.

Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates

BACKGROUND

Establishment of secure airway is a critical part of neonatal resuscitation both in the delivery room and in the neonatal unit. Videolaryngoscopy is a new technique that has the potential to facilitate successful endotracheal intubation and decrease adverse consequences of delay in airway stabilization. Videolaryngoscopy may enhance visualization of the glottis and intubation success in neonates.

OBJECTIVES

To determine the efficacy and safety of videolaryngoscopy compared to direct laryngoscopy in decreasing the time and attempts required and increasing the success rate for endotracheal intubation in neonates.

SEARCH METHODS

We used the search strategy of the Cochrane Neonatal Review Group. We searched for randomized controlled trials evaluating videolaryngoscopy for neonatal endotracheal intubation in May 2013 in the electronic databases; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; abstracts of the Pediatric Academic Societies; websites for registered trials at www.clinicaltrials.gov and www.controlled-trials.com; and in the reference lists of relevant studies.

SELECTION CRITERIA

Randomized or quasi-randomized trials in neonates evaluating videolaryngoscopy for endotracheal intubation compared with direct laryngoscopy.

DATA COLLECTION AND ANALYSIS

Review authors performed data collection and analysis as recommended by the Cochrane Neonatal Review Group. Two review authors (KL and MP) independently assessed studies identified by the search strategy for inclusion.

MAIN RESULTS

Our search strategy performed in May 2013 yielded 7057 references. Two review authors (MP and KL) independently assessed all references for inclusion. We did not find any completed studies for inclusion but identified three ongoing trials and one study awaiting classification.

AUTHORS' CONCLUSIONS

There was insufficient evidence to recommend or refute the use of videolaryngoscopy for endotracheal intubation in neonates. Well-designed, adequately powered randomized controlled studies are necessary to address efficacy and safety of videolaryngoscopy for endotracheal intubation in neonates.

Application of process improvement principles to increase the frequency of complete airway management documentation

BACKGROUND

Process improvement in healthcare delivery settings can be difficult, even when there is consensus among clinicians about a clinical practice or desired outcome. Airway management is a medical intervention fundamental to the delivery of anesthesia care. Like other medical interventions, a detailed description of the management methods should be documented. Despite this expectation, airway documentation is often insufficient. The authors hypothesized that formal adoption of process improvement methods could be used to increase the rate of "complete" airway management documentation.

METHODS

The authors defined a set of criteria as a local practice standard of "complete" airway management documentation. The authors then employed selected process improvement methodologies over 13 months in three iterative and escalating phases to increase the percentage of records with complete documentation. The criteria were applied retrospectively to determine the baseline frequency of complete records, and prospectively to measure the impact of process improvements efforts over the three phases of implementation.

RESULTS

Immediately before the initial intervention, a retrospective review of 23,011 general anesthesia cases over 6 months showed that 13.2% of patient records included complete documentation. At the conclusion of the 13-month improvement effort, documentation improved to a completion rate of 91.6% (P<0.0001). During the subsequent 21 months, the completion rate was sustained at an average of 90.7% (SD, 0.9%) across 82,571 general anesthetic records.

CONCLUSION

Systematic application of process improvement methodologies can improve airway documentation and may be similarly effective in improving other areas of anesthesia clinical practice.

Video laryngoscopes and the obstetric airway

The pitfalls surrounding securing the airway in the obstetric patient are well documented. From Tunstall's original failed intubation drill onwards, there has been progress both in recognition of the difficulties of airway management in the pregnant patient and development of algorithms to enhance patient safety. Current trends in obstetric anaesthesia have resulted in a significant decrease in exposure of anaesthetists, especially trainees, to caesarean section under general anaesthesia, compounding the difficulties in safely managing the airway. Video laryngoscopes have recently appeared in airway algorithms. They improve glottic visualisation and are useful in the management of the difficult non-obstetric airway, including those in morbidly obese patients and in the setting of a rapid-sequence induction. There is growing interest in the potential use of video laryngoscopes in the obstetric population and as a teaching tool to maximise training opportunities.

Tracheal intubation of pediatric manikins during ongoing chest compressions. Does Glidescope® videolaryngoscope improve pediatric residents' performance?

Our objective was to test the ability of pediatric residents to intubate the trachea of infant and child manikins during continuous chest compressions (CC) by means of indirect videolaryngoscopy with Glidescope® versus standard direct laryngoscopy. A randomized crossover simulation trial was designed. Twenty-three residents trained to intubate child and infant manikins were eligible for the study. They were asked to perform tracheal intubation in manikins assisted by both standard laryngoscopy and Glidescope® while a colleague delivered uninterrupted chest compressions. In the infant cardiac arrest scenario, the median (IQR) total time for intubation was significantly shorter with the Miller laryngoscope [28.2 s (20.4-34.4)] than with Glidescope® [38.0 s (25.3-50.5)] (p = 0.021). The number of participants who needed more than 30 s to intubate the manikin was also significantly higher with Glidescope® (n = 13) than with the Miller laryngoscope (n = 7, p = 0.01). In the child scenario, the total time for intubation and number of intubation failures were similar with Macintosh and Glidescope® laryngoscopes. The participants' subjective difficulty of the procedure was similar for direct and videolaryngoscopy.

CONCLUSION

In simulated infant and child cardiac arrest scenarios, pediatric residents are able to intubate the trachea during CC. The videolaryngoscope Glidescope® does not improve performance in this setting.

Pyriform sinus localization-assisted blind intubation: comparison with laryngoscopic intubation

BACKGROUND

Conventional endotracheal intubation requires laryngoscopy for a direct view of the glottis. However, laryngoscopy is associated with many potential complications. The aim of the present study was to compare the efficacy and safety of pyriform sinus localization-assisted blind orotracheal intubation with those of conventional laryngoscopic orotracheal intubation.

MATERIAL AND METHODS

A randomized, patient-blind, prospective study of 300 patients who underwent various operations was performed. One hundred patients were assigned to the laryngoscopic intubation group (laryngoscopy group), and 200 patients were assigned to the blind intubation group (blind group).

RESULTS

The total intubation success rate in the blind group was similar to that in the laryngoscopy group (100% vs. 99%, respectively; p=0.33). Oxygen saturation by pulse oximetry in both groups was maintained at >98%. The intubation time was significantly shorter in the blind group than in the laryngoscopy group (9.7±3.4 s vs. 23.0±5.8 s, respectively; p<0.001). Postoperative complication rates were significantly lower in the blind group than in the laryngoscopy group. Recovery time from these symptoms was significantly shorter in the blind group than in the laryngoscopy group (p=0.004).

CONCLUSIONS

Pyriform sinus localization-assisted blind orotracheal intubation was shown to be more effective than conventional laryngoscopic orotracheal intubation in terms of success rate, intubation time, and postoperative complication rate. Moreover, it is less affected by common risk factors; thus, this method may be more beneficial in patients with difficult airways.

Awake tracheal intubation using Pentax airway scope in 30 patients: A Case series

BACKGROUND AND AIMS

Pentax airway scope (AWS) has been successfully used for managing difficult intubations. In this case series, we aimed to evaluate the success rate and time taken to complete intubation, when AWS was used for awake tracheal intubation.

METHODS

We prospectively evaluated the use of AWS for awake tracheal intubation in 30 patients. Indication for awake intubation, intubation time, total time to complete tracheal intubation, laryngoscopic view (Cormack and Lehane grade), total dose of local anaesthetic used, anaesthetists rating and patient's tolerance of the procedure were recorded.

RESULTS

The procedure was successful in 25 out of the 30 patients (83%). The mean (standard deviation) intubation time and total time to complete the tracheal intubation was 5.4 (2.4) and 13.9 (3.7) min, respectively in successful cases. The laryngeal view was grade 1 in 24 and grade 2 in one of 25 successful intubations. In three out of the five patients where the AWS failed, awake tracheal intubation was successfully completed with the assistance of flexible fibre optic scope (FOS).

CONCLUSION

Awake tracheal intubation using AWS was successful in 83% of patients. Success rate can be further improved using a combination of AWS and FOS. Anaesthesiologists who do not routinely use FOS may find AWS easier to use for awake tracheal intubation using an oral route.

Videolaryngoscopy

The approach to airway management has undergone a dramatic transformation since the advent of videolaryngoscopy (VL). Videolaryngoscopes have quickly gained popularity as an intubation device in a variety of clinical scenarios and settings, as well as in the hands of airway experts and non-experts. Their indirect view of upper airway improves glottic visualization, including in suspected or encountered difficult intubation. Yet, more studies are needed to determine whether VL actually improves endotracheal intubation (ETI) success rates, intubation times, and first attempt success rates; and thereby a potential replacement to traditional direct laryngoscopy. Furthermore, advances in technology have heralded a wide array of models each with their own strengths, weaknesses, and optimal applications. Such limitations need to be better understood and alternative strategies should be available. Thus, the role of VL continues to evolve. Though it is clear VL expands the armamentarium not only for anesthesiologists, but all healthcare providers potentially involved in airway management.

Comparison of the Glidescope®, flexible fibreoptic intubating bronchoscope, iPhone modified bronchoscope, and the Macintosh laryngoscope in normal and difficult airways: a manikin study

Background

Smart phone technology is becoming increasingly integrated into medical care.

Our study compared an iPhone modified flexible fibreoptic bronchoscope as an intubation aid and clinical teaching tool with an unmodified bronchoscope, Glidescope® and Macintosh laryngoscope in a simulated normal and difficult airway scenario.

Methods

Sixty three anaesthesia providers, 21 consultant anaesthetists, 21 registrars and 21 anaesthetic nurses attempted to intubate a MegaCode Kelly™ manikin, comparing a normal and difficult airway scenario for each device. Primary endpoints were time to view the vocal cords (TVC), time to successful intubation (TSI) and number of failed intubations with each device. Secondary outcomes included participant rated device usability and preference for each scenario. Advantages and disadvantages of the iPhone modified bronchoscope were also discussed.

Results

There was no significant difference in TVC with the iPhone modified bronchoscope compared with the Macintosh blade (P = 1.0) or unmodified bronchoscope (P = 0.155). TVC was significantly shorter with the Glidescope compared with the Macintosh blade (P < 0.001), iPhone (P < 0.001) and unmodified bronchoscope (P = 0.011). The iPhone bronchoscope TSI was significantly longer than all other devices (P < 0.001). There was no difference between anaesthetic consultant or registrar TVC (P = 1.0) or TSI (P = 0.252), with both being less than the nurses (P < 0.001). Consultant anaesthetists and nurses had a higher intubation failure rate with the iPhone modified bronchoscope compared with the registrars. Although more difficult to use, similar proportions of consultants (14/21), registrars (15/21) and nurses (15/21) indicated that they would be prepared to use the iPhone modified bronchoscope in their clinical practice. The Glidescope was rated easiest to use (P < 0.001) and was the preferred device by all participants for the difficult airway scenario.

Conclusions

The iPhone modified bronchoscope, in its current configuration, was found to be more difficult to use compared with the Glidescope® and unmodified bronchoscope; however it offered several advantages for teaching fibreoptic intubation technique when video-assisted bronchoscopy was unavailable.

A systematic review of the role of videolaryngoscopy in successful orotracheal intubation

BACKGROUND

The purpose of our study was to organize the literature regarding the efficacy of modern videolaryngoscopes in oral endotracheal intubation, then perform a quality assessment according to recommended external criteria and make recommendations for use.

METHODS

Inclusion criteria included devices with recent studies of human subjects. A total of 980 articles were returned in the initial search and 65 additional items were identified using cited references. After exclusion of articles failing to meet study criteria, 77 articles remained. Data were extracted according to the rate of successful intubation and improvement of glottic view compared with direct laryngoscopy. Studies were classified according to whether they primarily examined subjects with normal airways, possessing risk factors for difficult direct laryngoscopy, or following difficult or failed direct laryngoscopy.

RESULTS

The evidence of efficacy for videolaryngoscopy in the difficult airway is limited. What evidence exists is both randomized prospective and observational in nature, requiring a scheme that evaluates both forms and allows recommendations to be made.

CONCLUSIONS

In patients at higher risk of difficult laryngoscopy we recommend the use of the Airtraq, CTrach, GlideScope, Pentax AWS and V-MAC to achieve successful intubation. In difficult direct laryngoscopy (C&L >/= 3) we cautiously recommend the use of the Airtraq, Bonfils, Bullard, CTrach, GlideScope, and Pentax AWS, by an operator with reasonable prior experience, to achieve successful intubation when used in accordance with the ASA practice guidelines for management of the difficult airway. There is additional evidence to support the use of the Airtraq, Bonfils, CTrach, GlideScope, McGrath, and Pentax AWS following failed intubation via direct laryngoscopy to achieve successful intubation. Future investigation would benefit from precise qualification of the subjects under study, and an improvement in overall methodology to include randomization and blinding.

The normal and the challenging pediatric airway

Management of a child's airway is one of the main sources of stress for anesthetists who do not routinely anesthetize children. Unfortunately, trainees are gaining less experience in pediatric airway management than in the past, which is particularly difficult at a time when some beliefs about airway management are being challenged and airway management is less standardized. Fortunately, most children have an easily managed, normal airway. Nevertheless, it is of vital importance to teach our trainees the basic airway skills that are probably the most important skill in an anesthetists' repertoire when it comes to a difficult airway situation. This review focuses on the airway management in children with a normal and a challenging airway. Different choices of airway management in children, and their advantages and disadvantages are discussed. Furthermore, the three broad causes of a challenging airway in children and infants are highlighted - the difficulty obtaining a mask seal, difficulty visualizing the vocal cords, and the third cause in which the larynx can be visualized but the difficulty lies at or beyond that level. Guidelines are given how to deal with these patients as well as with the feared but rare scenario of 'cannot ventilate, cannot intubate' in children.

The use of the Airtraq® optical laryngoscope for routine tracheal intubation in high-risk cardio-surgical patients

Background

The Airtraq^® optical laryngoscope (Prodol Ltd., Vizcaya, Spain) is a novel disposable device facilitating tracheal intubation in routine and difficult airway patients. No data investigating routine tracheal intubation using the Airtaq^® in patients at a high cardiac risk are available at present. Purpose of this study was to investigate the feasibility and hemodynamic implications of tracheal intubation with the Aitraq^® optical laryngoscope, in high-risk cardio-surgical patients.

Methods

123 consecutive ASA III patients undergoing elective coronary artery bypass grafting were routinely intubated with the Airtraq^® laryngoscope. Induction of anesthesia was standardized according to our institutional protocol. All tracheal intubations were performed by six anesthetists trained in the use of the Airtraq^® prior.

Results

Overall success rate was 100% (n = 123). All but five patients trachea could be intubated in the first attempt (95,9%). 5 patients were intubated in a 2nd (n = 4) or 3rd (n = 1) attempt. Mean intubation time was 24.3 s (range 16-128 s). Heart rate, arterial blood pressure and SpO₂ were not significantly altered. Minor complications were observed in 6 patients (4,8%), i.e. two lesions of the lips and four minor superficial mucosal bleedings. Intubation duration (p = 0.62) and number of attempts (p = 0.26) were independent from BMI and Mallampati score.

Conclusion

Tracheal intubation with the Airtraq^® optical laryngoscope was feasible, save and easy to perform in high-risk patients undergoing cardiac surgery. In all patients, a sufficient view on the vocal cords could be obtained, independent from BMI and preoperative Mallampati score.

Trial Registration

DRKS 00003230

A randomized comparison of the GlideScope videolaryngoscope to the standard laryngoscopy for intubation by pediatric residents in simulated easy and difficult infant airway scenarios

BACKGROUND

Videolaryngoscopy has been developed mainly to assist difficult airway intubation. However, there is a lack of studies demonstrating the real efficacy of its use in children. In this study, we tested the hypothesis that GlideScope (Verathon Inc, Bothell, Wash) videolaryngoscope improves tracheal intubation when used by pediatric residents in an advanced patient simulation model.

METHODS

Pediatric residents who passed a pediatric advanced life support course were eligible for the study. An advanced infant simulator was used, and 4 scenarios were proposed: normal airway (NA), tongue edema (TE), tongue edema and oropharyngeal edema, and cervical collar. No participant had prior experience with any videolaryngoscope. After a brief instruction in GlideScope technique, each participant performed the 4 scenarios using both the standard Miller and GlideScope laryngoscopes, in a random sequence.

RESULTS

Sixteen residents were included. The number of failed intubations was higher with GlideScope in NA and TE scenarios (3 vs 0, in both cases). Mean (SD) time to successful intubation was significantly longer with GlideScope in the NA scenario (GlideScope, 38 [SD, 13] vs Miller, 26 [SD, 16] seconds; P = 0.043). The number of maneuvers was significantly higher with GlideScope in the tongue edema and oropharyngeal edema scenario (2.3 [SD, 1.5] vs 1.5 [SD, 1]; P = 0.04). Upper jaw injury index was significantly lower with GlideScope in NA (2.0 [SD, 1] vs 2.6 [SD, 0.8]; P = 0.008) and cervical collar (2.1 [SD, 1.0] vs 2.8 [SD, 0.5]; P = 0.011) scenarios. Participants considered GlideScope technique more difficult than standard Miller in NA (5 [SD, 2.0] vs 3 [SD, 1.3]; P = 0.04) and TE (5.9 [SD, 2.5] vs 3.9 [SD, 1.7]; P = 0.02) scenarios.

CONCLUSIONS

In simulated scenarios of infant NA and difficult airway, when used by pediatric residents, GlideScope did not improve intubation performance when compared with the standard laryngoscope. Nevertheless, GlideScope may be safer for upper jaw injury and could have advantages in the management of complicated airway. Further studies are needed to assess if specific training will improve GlideScope intubation performance and whether the "in simulator" results translate into clinical practice.

Adoption of video laryngoscopy in Massachusetts emergency departments

BACKGROUND

Previous research suggests that video laryngoscopy may be superior to direct laryngoscopy.

OBJECTIVES

We sought to determine the proportion of Massachusetts emergency departments (EDs) that have adopted video laryngoscopy, the characteristics of user and non-user EDs, the reasons why non-users do not use video laryngoscopy, and how the adoption of video laryngoscopy compares to typical technology adoption life cycles.

METHODS

Surveys were mailed to directors of all non-federal EDs in Massachusetts (n=74) in early 2009. Non-responders received repeat mailings and were then contacted via telephone or e-mail.

RESULTS

Sixty-three of 74 (85%) EDs responded and 43% had adopted video laryngoscopy. EDs with video laryngoscopy had a higher median annual visit volume than EDs without video laryngoscopy (48,000 vs. 36,500, p=0.04), but had similar mean intubations per week (4.5 vs. 4.4, p=0.97) and mean surgical airways per year (0.7 vs. 1.1, p=0.19). Half of the EDs affiliated with emergency medicine residency programs had video laryngoscopy available. Among EDs with video laryngoscopy, the technology had been available for>5 years in 4% (1/27), 1-5 years in 44% (12/27), and<1 year in 52% (14/27). Although EDs not using video laryngoscopy did not do so primarily because it was too expensive (69% [25/36]), video laryngoscopy adoption has still progressed more rapidly than predicted by the typical technology adoption timeline.

CONCLUSION

Video laryngoscopy has been adopted by 43% of Massachusetts EDs; results were similar in academic institutions. Cost is the primary barrier to adoption for non-user EDs, but adoption is progressing more rapidly than expected for a new technology.

Comparison of the GlideScope Videolaryngoscope to the standard Macintosh for intubation by pediatric residents in simulated child airway scenarios

OBJECTIVES

Videolaryngoscopy may facilitate tracheal intubation in difficult airway scenarios. Our objective was to compare the ability of residents to intubate a child manikin using the standard Macintosh laryngoscope and the novel GlideScope.

METHODS

Pediatric residents who passed an advanced pediatric life support course were eligible. Four scenarios were proposed: Macintosh (M) and GlideScope (G) "easy" intubation and M and G "difficult"; intubation (cervical immobilization with rigid collar). No participant had previous experience with videolaryngoscope. Each participant performed the 4 scenarios in a random sequence. Time from initiation of intubation procedure to inflation of manikin's chest was recorded, as well as the number of intubation attempts, number of additional maneuvers, dental injury index, and participant's subjective impression.

RESULTS

Eighteen subjects were included. Median (range) time for easy airway intubation was 18 seconds (8-120 seconds) with M versus 37 seconds (18-96 seconds) with G (P = 0.029). Time for intubation with cervical immobilization was 19 seconds (9-120 seconds) with M versus 49 seconds (22-120 seconds) with G (P = 0.006). The G intubation in case of cervical immobilization needed significantly more maneuvers than with the M intubation (P = 0.014). There were no significant differences when number of attempts, dental injury index, and participant's subjective difficulty rate were compared.

CONCLUSIONS

Without specific training, videolaryngoscope-guided intubation did not improve intubation performance by pediatric residents in this manikin model of normal and simulated difficult intubation caused by a cervical collar in place. To achieve skills with videolaryngoscope intubation in children, a specific training program is needed.

Comparison of the Pentax Airway Scope and McGrath Videolaryngoscope with the Macintosh laryngoscope in tracheal intubation by anaesthetists unfamiliar with videolaryngoscopes: a manikin study

Videolaryngoscopes are becoming widely available and have been suggested as a replacement for the Macintosh in cases of cervical instability or even for use in the first instance. There is limited existing data on the use of videoscopes by experienced anaesthetists who are inexperienced in the use of videoscopes. We used a manikin model to compare time to intubation between the Macintosh blade, Pentax Airway Scope and the McGrath videolaryngoscope in a simulated urgent intubation by 23 experienced anaesthetists with no prior experience in the use of these videoscopes. We also measured the number of attempts and success of intubation within three minutes. Ease of device use and laryngoscopic view obtained were also recorded. We found that all participants could intubate the manikin within three minutes, with a median of one attempt using the Pentax Airway Scope. Only 48% of participants (n=11) could intubate within three minutes using the McGrath videolaryngoscope and required a median of three attempts. This difference occurred despite the majority of anaesthetists obtaining a Grade 1 Cormack and Lehane view with both videoscopes. We demonstrated that anaesthetists who were naive to these videoscopes can successfully intubate the trachea using the Pentax Airway Scope but not the McGrath videolaryngoscope.