Difficult Tracheal Intubation and Airway Outcomes after Radiation for Nasopharyngeal Carcinoma

OBJECTIVE

The aim of the study was to characterize the incidence and management of difficult tracheal intubations (DTIs) in nasopharyngeal carcinoma (NPC) after primary radiation therapy (RT).

METHODS

The study was a retrospective review of airway assessment and outcomes in post-RT NPC patients. Primary analysis was performed on patients who underwent post-RT procedures, who were split into non-DTI and DTI groups. Patients were classified as DTI if they (i) required >1 attempt to intubate, (ii) failed to be intubated, or (iii) experienced complications attributed to airway management. Secondary analysis was performed between patients who underwent post-RT procedures (procedure group) and those who did not (control group).

RESULTS

One-hundred and fifty patients were included, and 71.3% underwent post-RT procedures, with no differences in characteristics between the procedure and control groups. One-hundred and fifty procedures were identified, and 28.0% were categorized as DTI. There was no difference in patient characteristics or airway assessment measures between DTI and non-DTI groups. Regression analysis revealed concurrent cervical mobility restriction, and trismus increased DTI incidence by 7.1-fold (p = 0.011). Being non-White was an independent predictor of DTI. The incidence of high-grade intraoperative laryngoscopic view was lower in the non-DTI compared to the DTI group (20.4% vs. 64.3%, p < 0.0001). Failure to intubate occurred in 2.0% of cases, and 6.0% cases had perioperative complications. Based on preoperative assessment, sensitivity of predicting DTI was 54.8% and specificity was 63.9%.

CONCLUSION

NPC patients frequently undergo post-RT procedures requiring complex airway management. Rates of DTI and failed intubation are significantly higher than those in the general surgical population, and the ability to predict DTI with standard preoperative airway measures is poor.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:120-126, 2024.

A Manikin Study to Compare Video-Optical Intubation Stylet versus Macintosh Laryngoscope Used by Novice in Normal and Simulated Difficult Airway Intubation

Objective

To compare Macintosh laryngoscope with video-optical intubation stylet on rates and time durations of successful tracheal intubation in normal and simulated difficult airway.

Design

Crossover experimental study.

Setting

Intubation training laboratory.

Methods

A group of novices (58 medical students) attempted intubation on manikin under normal and simulated difficult airway (grade 3 larygnoscopic view) settings using both Macintosh laryngoscope and video-optical intubation stylet. The success rate, duration to intubate and occurrence of complications (oesophageal intubation and incisor breakage) when using the two different devices were measured and compared. The time results were analysed by paired t-test and categorical results by chi square test or Fisher's exact test.

Results

The success rate to intubate difficult airway using video-optical intubation stylet (0.92) was significantly higher than using Macintosh laryngoscope (0.59) (p=0.002). The mean time taken to intubate difficult airway using video-optical intubation stylet was significantly shorter than using Macintosh laryngoscope by 10.90 seconds (p=0.004). Oesophageal intubation rate was significantly higher when using Macintosh laryngoscope to intubate difficult airway compared to video-optical intubation stylet (p=0.002). There was no significant difference on the rate of incisor breakage between the two instruments.

Conclusions

Novice can learn to use both Macintosh laryngoscope and video-optical intubation stylet to intubate successfully after a short training. Video-optical intubation stylet is an effective “Plan B” instrument because it shortens the duration and increases the rate of successful intubation in difficult airway situations.

Can use of video Laryngoscopes by Emergency Medical Technicians Facilitate Endotracheal Intubation during Continuous Chest Compression? A Manikin Study

Introduction

We conducted this study to evaluate the utility of two video laryngoscopes (VLs) [Pentax-AWS (AWS), GlideScope (GVL)], compared to the conventional Macintosh laryngoscope (ML), on endotracheal intubation (ETI) involving chest compressions by Level 1 Korean emergency medical technicians (EMTs) who are the equivalent of EMT-I in the United States.

Methods

This was a randomised crossover simulation study. Fifty EMTs performed endotracheal intubation in randomised sequence following two different scenarios: normal airway and difficult airway.

Results

In normal airway scenario, overall success rate did not differ between the three devices. However AWS required a shorter run-time (14.1 [10.9-19.8] seconds) to complete ETI (TC) than ML (17.7 [13.5-21.3] seconds) (p=0.017). And both VLs showed a significant superiority over ML in time required to visualise vocal cords (TVC), percentage of glottic opening (POGO) score, and incidence of dental compression (IDC). In difficult airway scenario, overall success rate of both VLs was significantly higher than ML. The TC of AWS (13.7 [11.2-16.9] seconds) and GVL (20.7 [15.1-25.9] seconds) was shorter than that of ML (24.7 [18.1-34.5] seconds) (p<0.001). The TVC of GVL was significantly shorter than that of AWS and ML. The POGO score, IDC, and ease of intubation were significantly superior with AWS, GVL, and ML, respectively.

Conclusions

Video laryngoscopes can facilitate EMT performing a faster and easier intubation without interrupting chest compressions. Moreover, AWS improves the success rate comparing to ML in difficult airway management. (Hong Kong j.emerg.med. 2014;21:308-315)

Faucial Pillar Perforation by Glidescope Intubation with Incorrectly Placed Stylet

Glidescope GVL® is frequently used in intubation of difficult airway. We report a case of right side of faucial pillar perforation during intubation with Glidescope®. A rigid stylet can facilitate placing of endotracheal tube quickly but it may also penetrate the soft tissue to cause injuries.