Intubation of non-difficult airways using video laryngoscope versus direct laryngoscope: a randomized, parallel-group study

The Production, Assessment, and Utility of 3D-Printed Video Laryngoscopes in Eastern India: A Low-Cost Alternative to Conventional Video Laryngoscopes

Introduction Recognizing the limitations of traditional direct laryngoscopes, particularly in difficult airway situations, video laryngoscopy has emerged as a potentially safer and more effective alternative. This study evaluated the utility of two 3D-printed video laryngoscopes: a standard geometry video laryngoscope (SGVL), resembling the traditional Macintosh blade, and a hyper-angulated video laryngoscope (HAVL) with a more curved design. Their performance was compared to a standard Macintosh direct laryngoscope across various intubation parameters. By leveraging the cost-effectiveness of 3D printing with polylactic acid, the study aimed to assess the potential of this technology to improve airway management across diverse clinical settings and varying levels of physician expertise. Methods This prospective randomized crossover study compared the effectiveness of 3D-printed video laryngoscopes (VL) and a standard direct laryngoscope in intubation. After obtaining IRB approval, physicians from various specialties across multiple centers participated. Participants received training on SGVL, HAVL, and DL intubation using an instructional video and hands-on practice. The training was standardized for all participants. The primary outcome measures were time to successful intubation, number of attempts, and time to visualize vocal cords. Participants were randomized to use all three laryngoscopes on a manikin, with a maximum of two attempts per scope. A 30-minute break separated each laryngoscope evaluation. Successful intubation was defined as the single insertion of each laryngoscope and bougie, followed by endotracheal tube placement and confirmation of lung inflation. Results Ninety-eight doctors, mostly from the EM team (73.5%) and ICU team (23.4%). Teams consist of consultants, residents, and medical officers of the concerned departments. Forty-eight of the participants (49%) were novice operators (<25 intubations). Successful first-attempt intubation in those with <1 year of experience with intubation (n=33) was highest for SGVL (97%) compared to DL (82%) and HAVL (67%). Participants who learned intubation through self-directed learning exhibited a higher acceptance of VL and achieved 100% success on their first attempt. Among those who followed modules or workshops, 97% had successful first-attempt intubation with VL. The average time taken to visualize the vocal cords was lower in SGVL compared to DL (5.6 vs. 7.5 seconds) (p<0.001). The HAVL also had a lower average time compared to the DL (7.1 vs. 7.5 secs) (p<0.001). However, the time taken to intubate using DL (24.2 ±8.7 sec) was similar to SGVL (28.1 ±13 sec). Lastly, the intubation time using HAVL was the longest (49.6 ±35.5 sec). The time to intubate with DL and SGVL had Spearman's rho of 0.64 (p<0.001), and DL and HAVL had 0.59 (p<0.001). Conclusions The ease of use and its cost-effective nature make 3D-printed VLs beneficial in situations where traditional VLs may not be available, especially in simulation and training.

Individualized rotation of left double lumen endobronchial tube to improve placement success rate: a randomized controlled trial

BACKGROUND

In conventional practice, the left double lumen tube (DLT) is rotated 90° counterclockwise when the endobronchial cuff passes glottis. Success rate upon the first attempt is < 80%, likely owing to varying morphology of the bronchial bifurcation.

METHODS

We conducted a randomized controlled trial to compare 90° counterclockwise rotation versus individualized degree of rotation in adult patients undergoing elective thoracic surgery using left DLT. The degree of rotation in the individualized group was based on the angle of the left main bronchi as measured on computed tomography (CT). The primary outcome was the first attempt left DLT placement success rate.

RESULTS

A total of 556 patients were enrolled: 276 in the control group and 280 in the individualized group. The average angle of the left main bronchi was 100.6±9.5° (range 72° to 119°). The first attempt left DLT placement success rate was 82.6% (228/276) in the control group versus 91.4% (256/280) in the individualized group (P=0.02, χ2 test). The rate of carina mucosal injury, as measured at 30 min after the start of surgery under fibreoptic bronchoscopy, was significantly lower in individualized group than control group (14.0% versus 19.6%, P=0.041). The individualized group also had lower rate of postoperative sore throat (29.4% versus 44.0%, P<0.001) and hoarseness (16.8% versus 24.7%, P＜0.05).

CONCLUSIONS

Individualized rotation of left DLT based on the angle of the left main bronchi on preoperative CT increased first attempt success rate in adult patients undergoing elective thoracic surgery.

TRIAL REGISTRATION

The trial is registered at Chinese Clinical Trial Registry (ChiCTR2100053349; principal investigator Xiang Quan, date of registration November 19, 2021).

Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating Room: A Cluster Randomized Clinical Trial

Importance

Endotracheal tubes are typically inserted in the operating room using direct laryngoscopy. Video laryngoscopy has been reported to improve airway visualization; however, whether improved visualization reduces intubation attempts in surgical patients is unclear.

Objective

To determine whether the number of intubation attempts per surgical procedure is lower when initial laryngoscopy is performed using video laryngoscopy or direct laryngoscopy.

Design, Setting, and Participants

Cluster randomized multiple crossover clinical trial conducted at a single US academic hospital. Patients were adults aged 18 years or older having elective or emergent cardiac, thoracic, or vascular surgical procedures who required single-lumen endotracheal intubation for general anesthesia. Patients were enrolled from March 30, 2021, to December 31, 2022. Data analysis was based on intention to treat.

Interventions

Two sets of 11 operating rooms were randomized on a 1-week basis to perform hyperangulated video laryngoscopy or direct laryngoscopy for the initial intubation attempt.

Main Outcomes and Measures

The primary outcome was the number of operating room intubation attempts per surgical procedure. Secondary outcomes were intubation failure, defined as the responsible clinician switching to an alternative laryngoscopy device for any reason at any time, or by more than 3 intubation attempts, and a composite of airway and dental injuries.

Results

Among 8429 surgical procedures in 7736 patients, the median patient age was 66 (IQR, 56-73) years, 35% (2950) were women, and 85% (7135) had elective surgical procedures. More than 1 intubation attempt was required in 77 of 4413 surgical procedures (1.7%) randomized to receive video laryngoscopy vs 306 of 4016 surgical procedures (7.6%) randomized to receive direct laryngoscopy, with an estimated proportional odds ratio for the number of intubation attempts of 0.20 (95% CI, 0.14-0.28; P < .001). Intubation failure occurred in 12 of 4413 surgical procedures (0.27%) using video laryngoscopy vs 161 of 4016 surgical procedures (4.0%) using direct laryngoscopy (relative risk, 0.06; 95% CI, 0.03-0.14; P < .001) with an unadjusted absolute risk difference of -3.7% (95% CI, -4.4% to -3.2%). Airway and dental injuries did not differ significantly between video laryngoscopy (41 injuries [0.93%]) vs direct laryngoscopy (42 injuries [1.1%]).

Conclusion and Relevance

In this study among adults having surgical procedures who required single-lumen endotracheal intubation for general anesthesia, hyperangulated video laryngoscopy decreased the number of attempts needed to achieve endotracheal intubation compared with direct laryngoscopy at a single academic medical center in the US. Results suggest that video laryngoscopy may be a preferable approach for intubating patients undergoing surgical procedures.

Trial Registration

ClinicalTrials.gov Identifier: NCT04701762.

Comparison of the Effectiveness of the Miller Laryngoscope and the McGrath-MAC Video Laryngoscope in Direct Visualization of the Glottic Opening

Background and Objective: Placing the laryngoscope blade directly under the epiglottis (known as the direct view (DV) method) during videolaryngoscopy offers a superior view of the glottis when compared to the indirect method of lifting the epiglottis by positioning the Macintosh blade tip over the vallecula. While there are few studies comparing glottic views using Miller and Macintosh blades in pediatric patients, we have not come across such a study in adults. In this study, we aimed to compare the effectiveness and hemodynamic responses of the Miller laryngoscope and the McGrath-MAC videolaryngoscope (VL) in visualizing the glottic opening using the DV method. Material and Methods: A prospective study was conducted between August and December 2022 at XXX Hospital on 85 patients scheduled for surgical procedures involving endotracheal intubation. Patients were divided into two groups: Miller laryngoscope (Group M) and McGrath-MAC videolaryngoscope (Group VL) and intubated using the direct lifting method of the epiglottis. Hemodynamic responses before and after induction, as well as during laryngoscopy, intubation time, number of attempts, Cormack and Lehane (C&L) score, percentage of glottic opening (POGO), duration of the view of the opening, and need for external laryngeal pressure during intubation were recorded. Results: Both laryngoscopes showed similar effectiveness in terms of POGO and C&L score when used with the direct lifting method of the epiglottis. The median POGO values according to the DV method were 80% in Group M and 70% in Group VL (p = 0.099). Hemodynamic responses, intubation time, number of attempts, duration of view of the glottis opening, and the need for external laryngeal pressure were similar between the groups. Conclusions: Due to its ability to provide effective intubation conditions, we believe that the McGrath-MAC VL, when used with the indirect view method, can also be utilized in anesthesia practices alongside the DV method.

Conventional versus video-assisted laryngoscopy for perioperative endotracheal intubation (COVALENT) - a randomized, controlled multicenter trial

BACKGROUND

Data on the routine use of video-assisted laryngoscopy in peri-operative intubations are rather inconsistent and ambiguous, in part due to small populations and non-uniform outcome measures in past trials. Failed or prolonged intubation procedures are a reason for relevant morbidity and mortality. This study aims to determine whether video-assisted laryngoscopy (with both Macintosh-shaped and hyperangulated blades) is at least equal to the standard method of direct laryngoscopy with respect to the first-pass success rate. Furthermore, validated tools from the field of human factors will be applied to examine within-team communication and task load during this critical medical procedure.

METHODS

In this randomized, controlled, three-armed parallel group design, multi-centre trial, a total of more than 2500 adult patients scheduled for perioperative endotracheal intubation will be randomized. In equally large arms, video-assisted laryngoscopy with a Macintosh-shaped or a hyperangulated blade will be compared to the standard of care (direct laryngoscopy with Macintosh blade). In a pre-defined hierarchical analysis, we will test the primary outcome for non-inferiority first. If this goal should be met, the design and projected statistical power also allow for subsequent testing for superiority of one of the interventions. Various secondary outcomes will account for patient safety considerations as well as human factors interactions within the provider team and will allow for further exploratory data analysis and hypothesis generation.

DISCUSSION

This randomized controlled trial will provide a solid base of data in a field where reliable evidence is of major clinical importance. With thousands of endotracheal intubations performed every day in operating rooms around the world, every bit of performance improvement translates into increased patient safety and comfort and may eventually prevent significant burden of disease. Therefore, we feel confident that a large trial has the potential to considerably benefit patients and anaesthetists alike.

TRIAL REGISTRATION

ClincalTrials.gov NCT05228288.

PROTOCOL VERSION

1.1, November 15, 2021.

Change in glottic view during intubation using a KoMAC videolaryngoscope: A retrospective analysis

Intubation with videolaryngoscopy has become popular in various clinical settings. However, despite the use of a videolaryngoscope, difficult intubation still exists and intubation failure has been reported. This retrospective study assessed the efficacy of the 2 maneuvers in improving the glottic view during videolaryngoscopic intubation. The medical records of patients who underwent videolaryngoscopic intubation and whose glottal images were stored in electronic medical charts were reviewed. The videolaryngoscopic images were divided into 3 categories according to the applied optimization techniques as follows: conventional method, with the blade tip located in the vallecular; backward-upward-rightward pressure (BURP) maneuver; and epiglottis lifting maneuver. Four independent anesthesiologists scored the visualization of the vocal folds using the percentage of glottic opening (POGO, 0-100%) scoring system. A total of 128 patients with 3 laryngeal images were analyzed. The glottic view was the most improved in the epiglottis lifting maneuver among all the techniques. The median POGO scores were 11.3, 36.9, and 63.1 in the conventional method, BURP, and epiglottis lifting maneuver, respectively (P < .001). There were significant differences in the distribution of POGO grades according to the application of BURP and epiglottis lifting maneuvers. In the POGO grades 3 and 4 subgroups, the epiglottis lifting maneuver was more effective than the BURP maneuver in improving the POGO score Inadequate visualization of the vocal folds occurred even when intubation was performed using a videolaryngoscope. The application of optimization maneuvers, such as BURP and epiglottis lifting by the blade tip, could improve the glottic view.

Efficacy and safety of video laryngoscope in indwelling gastric tube in severe coma patients: A protocol for systematic review and meta-analysis

BACKGROUND

We designed this systematic review and meta-analysis protocol to provide new medical evidence for clinical management by comparing the prognostic outcomes of visual laryngoscopy with those of conventional blinded insertion methods.

METHODS

We will intend to search English databases including Medicine, Embase, Web of Science, Cochrane Central Register of Controlled Trials, Scopus, and Google Scholar. The Chinese databases, such as Wanfang, China Knowledge Network, and China Biomedical Literature Database will also be searched. The outcome measures include intubation success rate, pain score, intubation-related complications, patient satisfaction, operation time, and cost. The Jadad scale will be used to evaluate the methodological quality of each randomized controlled trial in this meta-analysis. We will use the Methodological Index of Non-Randomized Studies criteria to assess the risk of bias in non-randomized study. An I2 value greater than 50% indicates the presence of significant heterogeneity. P < .05 in a 2-tailed test is considered statistically significant.

RESULTS

It is hypothesized that video laryngoscope will provide better outcomes compared with traditional blind gastric tube insertion.

CONCLUSIONS

The results of our review will be reported strictly following the PRISMA criteria and the review will add to the existing literature by showing compelling evidence and improved guidance in clinic settings.

The effect of topical airway anesthesia on hemodynamic profiles during the induction period in patients undergoing cardiac surgery: Study protocol for a randomized controlled trial

Background

Patients scheduled for cardiac surgery are often accompanied by cardiac dysfunction and hemodynamic instability. However, the conventional induction strategy for anesthesia using high-dose intravenous anesthetics is often associated with persistent and recurrent hypotension after tracheal intubation. The purpose of this study is to investigate the effects of topical airway anesthesia on the hemodynamic profile of patients undergoing cardiac surgery during the induction period.

Methods

This is a superiority, single-blind, randomized controlled study with two parallel groups. Participants scheduled to undergo elective cardiac surgery will be allocated into two blocks according to the New York Heart Association (NYHA) classification and then randomly assigned to the following two groups at a 1:1 ratio: the conventional induction group and the combined topical airway anesthesia induction group. The combined topical airway anesthesia induction strategy includes aerosol inhalation airway anesthesia, subglottic airway anesthesia, and general anesthesia induction using low-dose intravenous anesthetics. The primary outcome is the area under the curve (AUC) of blood pressure below baseline mean arterial pressure (MAP) from 3 to 15 min after endotracheal intubation. Secondary outcomes include the AUC above baseline MAP and below baseline MAP at other time points, the highest and lowest arterial blood pressure values during the induction period, type and dose of vasoactive drugs, incidence of arrhythmias, cardiac function, and the incidence of postoperative hoarseness and sore throat.

Discussion

The study will explore whether aerosol inhalation airway anesthesia and subglottic airway anesthesia could reduce the incidence and duration of hypotension during the induction period in patients undergoing cardiac surgery.

Clinical Trial Registration

This trial was registered on www.ClinicalTrials.gov (NCT05323786).

Flexible Bronchoscope versus Video Laryngoscope for Orotracheal Intubation During Upper Gastrointestinal Endoscopic Surgery in Left Lateral Position: A Randomized Controlled Trial

Purpose

Endoscopic submucosal dissection (ESD) has become the primary treatment for early upper gastrointestinal tract lesions. During endoscopic surgery, endotracheal intubation is generally performed in the patients’ supine position, and patients are shifted to the left lateral position for endoscopic surgery. This study compared the efficacy of flexible bronchoscope-guided intubation with that of video laryngoscope-guided intubation in the left lateral position.

Patients and Methods

Forty-eight patients receiving ESD were randomly divided into the flexible bronchoscope group (group F) or the video laryngoscope group (group V). Tracheal intubation was performed by a trained anesthetist with a flexible bronchoscope (group F) or unchanneled video laryngoscope (group V) in the left lateral position. Primary outcomes included the intubation duration and success rate. Secondary outcomes included the ease of intubation technique and the occurrence of complications.

Results

Twenty-four (100%) patients in group F and twenty-three (95.8%) in group V were successfully intubated (P = 1.000). The median intubation time in group F was 37s (interquartile range, 33.0, 44.5), which was significantly shorter compared to group V (53s [45.5, 66.5]; P < 0.001). The flexible bronchoscope was significantly easier to manage than the video laryngoscope, as reflected by the users scoring system (9 [9, 10] vs 8 [7, 8]; P < 0.001). The presence of perioperative adverse events and complications were comparable between the two groups.

Conclusion

Both flexible bronchoscope- and video laryngoscope-guided intubation in patients’ left lateral position achieved high success rates and comparable complication rates. However, intubation with the flexible bronchoscope was completed more quickly.

Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation

BACKGROUND

Tracheal intubation is a common procedure performed to secure the airway in adults undergoing surgery or those who are critically ill. Intubation is sometimes associated with difficulties and complications that may result in patient harm. While it is traditionally achieved by performing direct laryngoscopy, the past three decades have seen the advent of rigid indirect videolaryngoscopes (VLs). A mounting body of evidence comparing the two approaches to tracheal intubation has been acquired over this period of time. This is an update of a Cochrane Review first published in 2016.

OBJECTIVES

To assess whether use of different designs of VLs in adults requiring tracheal intubation reduces the failure rate compared with direct laryngoscopy, and assess the benefits and risks of these devices in selected population groups, users and settings.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL and Web of Science on 27 February 2021. We also searched clinical trials databases, conference proceedings and conducted forward and backward citation searches.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs with adults undergoing laryngoscopy performed with either a VL or a Macintosh direct laryngoscope (DL) in any clinical setting. We included parallel and cross-over study designs.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We collected data for the following outcomes: failed intubation, hypoxaemia, successful first attempt at tracheal intubation, oesophageal intubation, dental trauma, Cormack-Lehane grade, and time for tracheal intubation.

MAIN RESULTS

We included 222 studies (219 RCTs, three quasi-RCTs) with 26,149 participants undergoing tracheal intubation. Most studies recruited adults undergoing elective surgery requiring tracheal intubation. Twenty-one studies recruited participants with a known or predicted difficult airway, and an additional 25 studies simulated a difficult airway. Twenty-one studies were conducted outside the operating theatre environment; of these, six were in the prehospital setting, seven in the emergency department and eight in the intensive care unit.  We report here the findings of the three main comparisons according to videolaryngoscopy device type. We downgraded the certainty of the outcomes for imprecision, study limitations (e.g. high or unclear risks of bias), inconsistency when we noted substantial levels of statistical heterogeneity and publication bias. Macintosh-style videolaryngoscopy versus direct laryngoscopy (61 studies, 9883 participants) We found moderate-certainty evidence that a Macintosh-style VL probably reduces rates of failed intubation (risk ratio (RR) 0.41, 95% confidence interval (CI) 0.26 to 0.65; 41 studies, 4615 participants) and hypoxaemia (RR 0.72, 95% CI 0.52 to 0.99; 16 studies, 2127 participants). These devices may also increase rates of success on the first intubation attempt (RR 1.05, 95% CI 1.02 to 1.09; 42 studies, 7311 participants; low-certainty evidence) and probably improve glottic view when assessed as Cormack-Lehane grade 3 and 4 (RR 0.38, 95% CI 0.29 to 0.48; 38 studies, 4368 participants; moderate-certainty evidence). We found little or no clear difference in rates of oesophageal intubation (RR 0.51, 95% CI 0.22 to 1.21; 14 studies, 2404 participants) but this finding was supported by low-certainty evidence. We were unsure of the findings for dental trauma because the certainty of this evidence was very low (RR 0.68, 95% CI 0.16 to 2.89; 18 studies, 2297 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 96%). Hyperangulated videolaryngoscopy versus direct laryngoscopy (96 studies, 11,438 participants) We found moderate-certainty evidence that hyperangulated VLs probably reduce rates of failed intubation (RR 0.51, 95% CI 0.34 to 0.76; 63 studies, 7146 participants) and oesophageal intubation (RR 0.39, 95% CI 0.18 to 0.81; 14 studies, 1968 participants). In subgroup analysis, we noted that hyperangulated VLs were more likely to reduce failed intubation when used on known or predicted difficult airways (RR 0.29, 95% CI 0.17 to 0.48; P = 0.03 for subgroup differences; 15 studies, 1520 participants). We also found that these devices may increase rates of success on the first intubation attempt (RR 1.03, 95% CI 1.00 to 1.05; 66 studies, 8086 participants; low-certainty evidence) and the glottic view is probably also improved (RR 0.15, 95% CI 0.10 to 0.24; 54 studies, 6058 participants; data for Cormack-Lehane grade 3/4 views; moderate-certainty evidence). However, we found low-certainty evidence of little or no clear difference in rates of hypoxaemia (RR 0.49, 95% CI 0.22 to 1.11; 15 studies, 1691 participants), and the findings for dental trauma were unclear because the certainty of this evidence was very low (RR 0.51, 95% CI 0.16 to 1.59; 30 studies, 3497 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 99%). Channelled videolaryngoscopy versus direct laryngoscopy (73 studies, 7165 participants) We found moderate-certainty evidence that channelled VLs probably reduce rates of failed intubation (RR 0.43, 95% CI 0.30 to 0.61; 53 studies, 5367 participants) and hypoxaemia (RR 0.25, 95% CI 0.12 to 0.50; 15 studies, 1966 participants). They may also increase rates of success on the first intubation attempt (RR 1.10, 95% CI 1.05 to 1.15; 47 studies, 5210 participants; very low-certainty evidence) and probably improve glottic view (RR 0.14, 95% CI 0.09 to 0.21; 40 studies, 3955 participants; data for Cormack-Lehane grade 3/4 views; moderate-certainty evidence). We found little or no clear difference in rates of oesophageal intubation (RR 0.54, 95% CI 0.17 to 1.75; 16 studies, 1756 participants) but this was supported by low-certainty evidence. We were unsure of the findings for dental trauma because the certainty of the evidence was very low (RR 0.52, 95% CI 0.13 to 2.12; 29 studies, 2375 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 98%).

AUTHORS' CONCLUSIONS

VLs of all designs likely reduce rates of failed intubation and result in higher rates of successful intubation on the first attempt with improved glottic views. Macintosh-style and channelled VLs likely reduce rates of hypoxaemic events, while hyperangulated VLs probably reduce rates of oesophageal intubation. We conclude that videolaryngoscopy likely provides a safer risk profile compared to direct laryngoscopy for all adults undergoing tracheal intubation.

Addition of topical airway anaesthesia to conventional induction techniques to reduce haemodynamic instability during the induction period in patients undergoing cardiac surgery: protocol for a randomised controlled study

INTRODUCTION

The aim of this prospective study is to evaluate the effects of combining topical airway anaesthesia with intravenous induction on haemodynamic variables during the induction period in patients undergoing cardiac surgery.

METHODS AND ANALYSIS

This randomised, double-blind, controlled, parallel-group, superiority study from 1 March 2021 to 31 December 2021 will include 96 participants scheduled for cardiac surgery. Participants will be screened into three blocks (ASA II, ASA III, ASA IV) according to the American Society of Anesthesiologists (ASA) grade and then randomly allocated into two groups within the block in a 1:1 ratio. Concealment of allocation will be maintained using opaque, sealed envelopes generated by a nurse according to a computer-generated randomisation schedule. In addition to general intravenous anaesthetics, participants will receive supraglottic and subglottic topical anaesthesia. Changes in arterial blood pressure and heart rate in both groups will be recorded by an independent investigator at the start of anaesthesia induction until the skin incision. If vasopressors are used during this period, the frequency, dosage and types of vasopressors will be recorded. The incidence and severity of participants' postoperative hoarseness and sore throat will also be assessed.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of Qianfoshan Hospital of Shandong Province (registration number: YXLL-KY-2021(003)). The results will be disseminated through a peer-reviewed publication and in conferences or congresses.

TRIAL REGISTRATION NUMBER

NCT04744480.

An initial learning experience of tracheal intubation with video laryngoscope: Experiences from a novice PGY

Tracheal intubation is an essential technique for many healthcare professionals and one of the mega code simulations in advanced cardiac life support. In recent years, video laryngoscopy (VL) has provided a rescue for difficult airways during intubation and has proven to have higher success rates. Moreover, VL facilitates a more rapid learning curve for inexperienced doctors.In this article, we report 16 cases intubated with VL by a novice doctor of postgraduate year 1, who shared the learning experience and the difficulties encountered in this case series. We also conducted a statistical analysis to evaluate the learning outcomes of the trainee after 1 month.Our results showed that the overall first-shot success rate was 81.3% for the 16 objectives. Over time, improvements in intubation performance measures, including shortened duration and lower Intubation Difficulty Scale score, have been observed. In this learning project, we found that limitation of mouth opening (<2.5 fingers wide) is an important risk factor for predicting the initial difficulty of tracheal intubation on the novice trainee.For inexperienced doctors, VL produces high first-shot success rates for tracheal intubation and may be useful for training their performance in a short period of time. In addition, mouth opening <3 fingers wide may result in difficult intubation by novice doctors.

Economic analysis of the use of video laryngoscopy versus direct laryngoscopy in the surgical setting

Aim: Compared with direct laryngoscopy (DL), video laryngoscopy (VL) offers clinical benefits in routine and difficult airways. The health economic benefit of VL versus DL for routine tracheal intubation remains unknown. Materials & methods: This analysis compared VL and DL health economic outcomes, including total inpatient costs, length of hospital stay (LOS), postoperative intensive care unit (ICU) admission and incidence of procedurally associated complications. Results: Patients with VL had decreased inpatient cost (US$1144-5891 across eight major diagnostic categories [MDC]); >1-day LOS reduction in five MDC; reduced odds for postoperative ICU admission (0.04-0.68) and reduced odds of respiratory complications in three MDC (0.43-0.90). Conclusion: Video laryngoscopy may lower total costs, reduce LOS and decrease the likelihood of postoperative ICU admission.

A comparative study of glottis visualization according to the method of lifting the epiglottis in video laryngoscopy: indirect and direct lifting methods

BACKGROUND

The direct entry of the camera under the epiglottis may provide a better view of the glottis than the indirect lifting of the epiglottis by placing the Macintosh blade tip on the vallecula when using the video laryngoscope. This study aimed to compare the efficiency of two different methods of lifting the epiglottis during the visualization of glottis using video laryngoscopy in the same patient.

METHODS

This prospective study enrolled 60 patients who underwent general anesthesia with tracheal intubation. In each patient, glottic views were obtained by directly (group DE) and indirectly lifting the epiglottis (group IE). These two methods were compared using the modified Cormack and Lehane grade and the percentage of glottis opening (POGO) score as assessment parameters.

RESULTS

Modified Cormack and Lehane grade showed a significant difference between the groups DE and IE (P = 0.004). The difference in the POGO score between the groups DE and IE was also statistically significant (87.5% and 64.4%, respectively; P < 0.001).

CONCLUSIONS

Our results, therefore, revealed that the method of directly lifting epiglottis was better at exposing glottis than the method of indirectly lifting epiglottis using a video laryngoscope.

A Practical Guide for Anesthesia Providers on the Management of Coronavirus Disease 2019 Patients in the Acute Care Hospital

The coronavirus disease 2019 (COVID-19) pandemic has infected millions of individuals and posed unprecedented challenges to health care systems. Acute care hospitals have been forced to expand hospital and intensive care capacity and deal with shortages in personal protective equipment. This guide will review 2 areas where the anesthesiologists will be caring for COVID-19 patients: the operating room and on airway teams. General principles for COVID-19 preparation and hospital procedures will be reviewed to serve as a resource for anesthesia departments to manage COVID-19 or future pandemics.

Barrier Enclosure for Endotracheal Intubation in a Simulated COVID-19 Scenario: A Crossover Study

Introduction

Barrier enclosures have been developed to reduce the risk of COVID-19 transmission to healthcare providers during intubation, but little is known about their impact on procedure performance. We sought to determine whether a barrier enclosure delays time to successful intubation by experienced airway operators.

Methods

We conducted a crossover simulation study at a tertiary academic hospital. Participants watched a four-minute video, practiced one simulated intubation with a barrier enclosure, and then completed one intubation with and one without the barrier enclosure (randomized to determine order). The primary outcome measure was time from placement of the video laryngoscope at the lips to first delivered ventilation. Secondary outcomes were periprocedural complications and participant responses to a post-study survey.

Results

Proceduralists (n = 50) from emergency medicine and anesthesiology had median intubation times of 23.6 seconds with practice barrier enclosure, 20.5 seconds with barrier enclosure, and 16.7 seconds with no barrier. Intubation with barrier enclosure averaged 4.5 seconds longer (95% confidence interval, 2.7–6.4, p < .001) than without, but was less than the predetermined clinical significance threshold of 10 seconds. Three complications occurred, all during the practice intubation. Barrier enclosure made intubation more challenging according to 48%, but 90% indicated they would consider using it in clinical practice.

Conclusion

Experienced airway operators performed intubation using a barrier enclosure with minimal increased time to procedure completion in this uncomplicated airway model. Given potential to reduce droplet spread, use of a barrier enclosure may be an acceptable adjunct to endotracheal intubation for those familiar with its use.