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Wiles MD, Iliff HA, Brooks K, Da Silva EJ, Donnellon M, Gardner A, Harris M, Leech C, Mathieu S, Moor P, Prisco L, Rivett K, Tait F, El-Boghdadly K. Airway management in patients with suspected or confirmed cervical spine injury: Guidelines from the Difficult Airway Society (DAS), Association of Anaesthetists (AoA), British Society of Orthopaedic Anaesthetists (BSOA), Intensive Care Society (ICS), Neuro Anaesthesia and Critical Care Society (NACCS), Faculty of Prehospital Care and Royal College of Emergency Medicine (RCEM). Anaesthesia 2024; 79:856-868. [PMID: 38699880 DOI: 10.1111/anae.16290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND There are concerns that airway management in patients with suspected or confirmed cervical spine injury may exacerbate an existing neurological deficit, cause a new spinal cord injury or be hazardous due to precautions to avoid neurological injury. However, there are no evidence-based guidelines for practicing clinicians to support safe and effective airway management in this setting. METHODS An expert multidisciplinary, multi-society working party conducted a systematic review of contemporary literature (January 2012-June 2022), followed by a three-round Delphi process to produce guidelines to improve airway management for patients with suspected or confirmed cervical spine injury. RESULTS We included 67 articles in the systematic review, and successfully agreed 23 recommendations. Evidence supporting recommendations was generally modest, and only one moderate and two strong recommendations were made. Overall, recommendations highlight key principles and techniques for pre-oxygenation and facemask ventilation; supraglottic airway device use; tracheal intubation; adjuncts during tracheal intubation; cricoid force and external laryngeal manipulation; emergency front-of-neck airway access; awake tracheal intubation; and cervical spine immobilisation. We also signpost to recommendations on pre-hospital care, military settings and principles in human factors. CONCLUSIONS It is hoped that the pragmatic approach to airway management made within these guidelines will improve the safety and efficacy of airway management in adult patients with suspected or confirmed cervical spine injury.
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Affiliation(s)
- Matthew D Wiles
- Department of Anaesthesia and Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Centre for Applied Health and Social Care Research, Sheffield Hallam University, Sheffield, UK
| | | | | | - Egidio J Da Silva
- Department of Anaesthesia, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Mike Donnellon
- Education and Standards Committee, College of Operating Department Practitioners, London, UK
| | - Adrian Gardner
- Department of Spine Surgery, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
- Aston University, Birmingham, UK
| | - Matthew Harris
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Caroline Leech
- Department of Emergency Medicine, Institute for Applied and Translational Technologies in Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
- Prehospital Emergency Medicine, Air Ambulance Service, Rugby, UK
| | - Steve Mathieu
- Department of Critical Care, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Paul Moor
- Army Health Branch, Army HQ, Marlborough Lines, Andover, Hants, UK
- Department of Anaesthesia, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Lara Prisco
- Neurosciences Intensive Care Unit, John Radcliffe Hospital, Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Kate Rivett
- Patient Representative, Difficult Airway Society, London, UK
| | - Frances Tait
- Critical Care Department, Northampton General Hospital, Northampton, UK
| | - Kariem El-Boghdadly
- Department of Anaesthesia and Perioperative Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
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Singleton BN, Morris FK, Yet B, Buggy DJ, Perkins ZB. Effectiveness of intubation devices in patients with cervical spine immobilisation: a systematic review and network meta-analysis. Br J Anaesth 2021; 126:1055-1066. [PMID: 33610262 DOI: 10.1016/j.bja.2020.12.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/14/2020] [Accepted: 12/27/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Cervical spine immobilisation increases the difficulty of tracheal intubation. Many intubation devices have been evaluated in this setting, but their relative performance remains uncertain. METHODS MEDLINE, EMBASE, and the Cochrane Library were searched to identify randomised trials comparing two or more intubation devices in adults with cervical spine immobilisation. After critical appraisal, a random-effects network meta-analysis was used to pool and compare device performance. The primary outcome was the probability of first-attempt intubation success (first-pass success). For relative performance, the Macintosh direct laryngoscopy blade was chosen as the reference device. RESULTS We included 80 trials (8039 subjects) comparing 26 devices. Compared with the Macintosh, McGrath™ (odds ratio [OR]=11.5; 95% credible interval [CrI] 3.19-46.20), C-MAC D Blade™ (OR=7.44; 95% CrI, 1.06-52.50), Airtraq™ (OR=5.43; 95% CrI, 2.15-14.2), King Vision™ (OR=4.54; 95% CrI, 1.28-16.30), and C-MAC™ (OR=4.20; 95% CrI=1.28-15.10) had a greater probability of first-pass success. This was also true for the GlideScope™ when a tube guide was used (OR=3.54; 95% CrI, 1.05-12.50). Only the Airway Scope™ had a better probability of first-pass success compared with the Macintosh when manual-in-line stabilisation (MILS) was used as the immobilisation technique (OR=7.98; 95% CrI, 1.06-73.00). CONCLUSIONS For intubation performed with cervical immobilisation, seven devices had a better probability of first-pass success compared with the Macintosh. However, more studies using MILS (rather than a cervical collar or other alternative) are needed, which more accurately represent clinical practice. CLINICAL TRIAL REGISTRATION PROSPERO 2019 CRD42019158067 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=158067).
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Affiliation(s)
- Barry N Singleton
- Department of Anaesthesiology and Critical Care Medicine, Our Lady's Children's Hospital Crumlin, Dublin, Ireland.
| | - Fiachra K Morris
- Department of Anaesthesiology and Critical Care Medicine, Beaumont Hospital, Dublin, Ireland
| | - Barbaros Yet
- Graduate School of Informatics, Middle East Technical University, Ankara, Turkey
| | - Donal J Buggy
- Department of Anaesthesiology and Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland
| | - Zane B Perkins
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
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Jakhar R, Saigal D, Kale S, Aggarwal S. Comparison of Videolaryngoscope and Intubating Laryngeal Mask Airway for Tracheal Intubation with Manual-in-line Stabilization in Patients Undergoing Cervical Spine Surgery. Anesth Essays Res 2020; 14:485-491. [PMID: 34092863 PMCID: PMC8159048 DOI: 10.4103/aer.aer_90_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/01/2020] [Accepted: 10/06/2020] [Indexed: 11/25/2022] Open
Abstract
Background: This prospective, randomized study compared CMAC® videolaryngoscope with intubating laryngeal mask airway (ILMA) for intubation under manual-in-line-stabilization (MILS) in patients undergoing cervical spine surgery. Settings and Design: Sixty-five ASA Physical Status Classes I and II patients aged 18–65 years undergoing elective cervical spine surgery were randomly allocated into two groups: group CM-intubation with CMAC® videolaryngoscope (n = 33) and Group IL-intubation using ILMA (n = 32). Materials and Methods: Intubation was performed in all patients after the application of MILS. The primary outcomes included first attempt and overall intubation success rate, intubation time, and apnea time. The secondary objectives were degree of head movement, hemodynamic response, incidence of desaturation, sore throat, and tissue injury. Statistical Analysis: Normality of data was tested by the Kolmogorov–Smirnov test. Quantitative variables were compared using the unpaired t-test or Wilcoxon Mann–Whitney test and qualitative variables were compared using the Chi-square test/Fisher's exact test. P < 0.05 was considered statistically significant. Results: CM group had a higher first attempt (96.97%, P = 0.054) and overall (100%, P = 0.053) intubation success rate than IL group (81.25% and 87.5%, respectively). Group CM had a significantly shorter (P < 0.0001) intubation time (33.13 ± 11.82 s) than IL group (55.71 ± 19.28 s), but group CM had significantly longer (P < 0.0001) apnea time (33.13 ± 11.82 s) than IL group (22.03 ± 7.14 s). The incidence of head movement was significantly lower in IL group (P = 0.011). Hypoxemia did not occur. Postintubation hemodynamic changes and tissue injury were significantly higher in ILMA group. Conclusion: CMAC group had higher intubation success rate and significantly shorter intubation time. However, ILMA group had a significantly shorter apnea time and significantly lower incidence of head movements.
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Affiliation(s)
- Reena Jakhar
- Department of Anaesthesiology and Critical Care, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Deepti Saigal
- Department of Anaesthesiology and Critical Care, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Suniti Kale
- Department of Anaesthesiology and Critical Care, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Shipra Aggarwal
- Department of Anaesthesiology and Critical Care, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Liao CC, Liu FC, Li AH, Yu HP. Video laryngoscopy-assisted tracheal intubation in airway management. Expert Rev Med Devices 2018; 15:265-275. [DOI: 10.1080/17434440.2018.1448267] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Chia-Chih Liao
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Fu-Chao Liu
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Allen H. Li
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Huang-Ping Yu
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
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