Comparison of intubation times using a manikin with an immobilized cervical spine: Macintosh laryngoscope vs. GlideScope vs. fiberoptic bronchoscope

Prediction of difficult airway management in traumatic cervical spine injury: influence of retropharyngeal space extension

Background

Retropharyngeal hematoma following cervical spine trauma may lead to life-threatening upper airway obstruction and difficult airway management. This retrospective study was performed to investigate whether the extension of retropharyngeal space (RPS) was associated with difficult intubation by direct laryngoscopy in traumatic cervical spine injury.

Patients and methods

Sixty-two patients who had undergone direct endotracheal intubation under general anesthesia for cervical spine surgery were retrospectively identified. Laryngoscopic grade by Cormack–Lehane (C-L) classification was collected; grade 1 or 2 was categorized as easy laryngoscopy, whereas grade 3 or 4 was categorized as difficult laryngoscopy. In these patients, RPS thickness and the proportions of RPS to the vertebral bodies were measured at the 2nd, 5th and 7th cervical spine levels using magnetic resonance imaging (MRI) of the cervical spine. Measures of RPS were compared between easy and difficult laryngoscopy. Relationships between measures of RPS and difficult laryngoscopy were analyzed with logistic regression analysis.

Results

RPS thickness at C2 was significantly greater in difficult laryngoscopy (median 14.29 mm, IQR: 9.75–18.04) than easy laryngoscopy (median 5.10, IQR: 4.33–5.94, p<0.001). Proportion of RPS to the C2 vertebral body were significantly higher in difficult laryngoscopy than in easy laryngoscopy (p<0.001). RPS thickness and the proportion of RPS to the vertebral body were significantly associated with difficult laryngoscopy (OR=2.13, 95% CI: 1.38–3.30; p<0.001 and OR=1.13, 95% CI: 1.05–1.21; p<0.001, respectively).

Conclusion

RPS extension at the upper cervical spine level is associated with difficult direct laryngoscopy in traumatic cervical spine injury.

Confirmation of endotracheal tube placement using disposable fiberoptic bronchoscopy in the emergent setting

BACKGROUND

Patients intubated in the prehospital setting require quick and definitive confirmation of endotracheal (ET) tube placement upon arrival to the emergency department (ED). Direct and adjunct strategies exist, but each has limitations and there is no definitive gold standard. The utility of bronchoscopy in ED intubation has been studied, but scant literature exists on its use for ET tube confirmation. This study aims to assess effectiveness, ease and speed with which ET tube placement can be confirmed with disposable fiberoptic bronchoscopy.

METHODS

Emergency medicine residents recruited from a 3-year urban residency program received 5 minutes of active learning on a simulation mannequin using a disposable, flexible Ambu aScope interfaced with a monitor. With residents blinded, the researcher randomly placed the ET tube in the trachea, esophagus or right mainstem. Residents identified ET tube position by threading the bronchoscope through the tube and viewing distal anatomy. Each resident underwent 4 trials. Accuracy, speed and perceptions of difficulty were measured.

RESULTS

Residents accurately identified the location of the ET tube in 88 out of 92 trials (95.7%). The median time-to-guess was 7.0 seconds, IQR (5.0-10.0). Average perceived difficulty was 1.6 on a scale from 1-5 (1 being very easy and 5 being very difficult). No tubes were damaged or dislodged.

CONCLUSION

While simulation cannot completely replicate the live experience, fiberoptic bronchoscopy appears to be a quick and accurate method for ET tube confirmation. Further studies directly comparing this novel approach to established practices on actual patients are warranted.

Laryngoscopes for difficult airway scenarios: a comparison of the available devices

INTRODUCTION

According to the American Society of Anesthesiologists, the incidence of difficult intubation in the operating room is 1.2-3.8%; however, in emergency conditions, this rate is higher and reaches even 5.3%. Successful emergency airway management is an essential component of the modern practice of medicine.

AREAS COVERED

The aim of the study is to review the literature regarding different devices used to perform endotracheal intubation (Macintosh, Miller, and McCoy laryngoscopes; ETView, GlideScope, TruView, Airtraq, McGrath MAC, Pentax AWS, Trachlight, Shikani, and Bullard) and discuss their clinical and experimental role in difficult airway management.

EXPERT COMMENTARY

Owing to the development of medical technology, there are an increasing number of videolaryngoscopes and other devices facilitating endotracheal intubation in difficult airway scenarios, including cardiopulmonary resuscitation, cervical spine injury, or face-to-face intubation. Each of these devices may bring benefits in the form of increasing the intubation effectiveness, as well as shortening the procedure, provided that the person performing intubation is familiar with the use of the device.

Comparison of the ETView Single Lumen and Macintosh laryngoscopes for endotracheal intubation in an airway manikin with immobilized cervical spine by novice paramedics: A randomized crossover manikin trial

CONTEXT

Management of the airway of a trauma victim is considered challenging. Various approaches have been described to achieve airway control in this setup; many of them include video-assited viewing of the larynx during intubation. ETView Single Lumen (SL) is a novice single-use endotracheal tube equiped with a video camera and a light source at its distal tip. Its use was previously described in seeral clinical and training setups.

OBJECTIVE

The aim was to evaluate the efficacy of the VivaSight SL compared with classic direct laryngoscopy performed with a Macintosh blade in a manikin-simulated trauma setup presenting various degrees of airway challenge when performed by inexperienced physicians.

DESIGN, SETTING, PARTICIPANTS

This was prospective, randomized, crossover, manikin trial. After short training on the ETView system, 67 novice paramedics attempted to perform oral intubation using both standard direct laryngoscopy (MAC group) and the VivaSight SL endotracheal tube (ETView group) in a randomized order on manikins in 3 increasingly more difficult scenarios (simple intubation, cervical spine manual stabilization, and with cervical collar in place).

OUTCOME MEASURE

Overall success rate, time to intubation, number of intubation attempts, laryngeal view grade, dental compression, and overall participant satisfaction were monitored.

RESULTS

Duration of intubation and number of attempts were significantly superior in the ETView group in the latter 2 more challenging scenarios. All other parameters showed superiority to the ETView group in all 3 scenarios.

CONCLUSION

The VivaSight SL system performed better in a complex scenario of airway management of a trauma victim in need for cervical spine stabilization performed by novice caregivers compared to standard direct laryngoscopy and should be considered in this clinical setup.