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Hung TY, Tseng CW, Wen CS, Yu SH, Chen HL, Lee CW, Su YC, Lin CH. Video-stylet vs. channeled hyperangulated videolaryngoscope: Efficacy in simulated Ludwig's angina randomized cadaver trial. Am J Emerg Med 2024; 76:63-69. [PMID: 37995525 DOI: 10.1016/j.ajem.2023.11.006] [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] [Received: 07/11/2023] [Revised: 10/26/2023] [Accepted: 11/01/2023] [Indexed: 11/25/2023] Open
Abstract
INTRODUCTION Ludwig's angina (LA) is a life-threatening infection that can affect the floor of the mouth and neck, potentially causing serious airway obstruction. In such cases, rescue airway management and oxygenation can be challenging due to swelling of the mouth floor, trismus, and limited mouth opening. The aim of this study was to assess the efficacy of the Trachway video-stylet (VS) and Pentax AWS hyperangulated videolaryngoscope with channel (HAVL-C) compared to the standard geometric video-laryngoscope (SGVL, Macintosh 3, Trachway) in simulating Ludwig's angina with cadavers. METHODS Three fresh frozen cadavers were prepared with varying degrees of difficulty to simulate the airway conditions of patients with LA, including mouth floor swelling, restricted mouth opening, and trismus. Fifty-five second-year resident physicians from various specialties participated in the study and received training in airway management using SGVL, VS, and HAVL-C devices. Participants were randomly assigned to intubate simulated LA with cadavers using the three devices in a random order, and intubation times and success rates were recorded. Participants also rated the difficulty of intubation using a visual analogue scale (VAS) score. The primary outcome assessed the first-pass intubation success or failure, while the secondary outcomes measured the intubation time and subjective difficulty using a visual analogue scale with different laryngoscopes. RESULTS The success rates for intubation within 90 s were 40% for SGVL, 82% for VS, and 76% for HAVL-C. VS and HAVL-C had significantly higher success rates than SGVL, with hazard ratios of 3.4 and 2.7, and 95% confidence intervals (CI) of 2.0-5.7 and 1.6-4.6, p < 0.001, respectively. The odds ratios of successful intubation for VS and HAVL-C were 8.1 and 6.3, respectively, with a 95% CI of 3.7-17.8 and 2.4-16.7, p < 0.001, compared to SGVL. The VAS score was significantly correlated with intubation success rate and time. CONCLUSIONS In cases of LA, the use of VS and HAVL-C is preferable over SGVL. These findings suggest that using VS and HAVL-C can improve intubation success rates and reduce intubation time in patients with LA.
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Affiliation(s)
- Tzu-Yao Hung
- Department of Emergency Medicine, Zhong-Xing branch, Taipei City Hospital, Taipei City, Taiwan; Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan; CrazyatLAB (Critical Airway Training Laboratory), Taipei City, Taiwan.
| | - Cheng-Wei Tseng
- Department of Emergency Medicine, Zhong-Xing branch, Taipei City Hospital, Taipei City, Taiwan
| | - Chung-Shiung Wen
- Department of Emergency Medicine, Zhong-Xing branch, Taipei City Hospital, Taipei City, Taiwan
| | - Sheng-Han Yu
- Department of Emergency Medicine, Zhong-Xing branch, Taipei City Hospital, Taipei City, Taiwan
| | - Hsin-Ling Chen
- Department of Emergency Medicine, Zhong-Xing branch, Taipei City Hospital, Taipei City, Taiwan
| | - Chen-Wei Lee
- CrazyatLAB (Critical Airway Training Laboratory), Taipei City, Taiwan; School of Medicine, Tzu Chi University, Hualien County, Taiwan; Department of Emergency, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi City, Taiwan.
| | - Yung-Cheng Su
- School of Medicine, Tzu Chi University, Hualien County, Taiwan; Department of Emergency, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi City, Taiwan
| | - Chieh-Hung Lin
- Department of Emergency Medicine, Zhong-Xing branch, Taipei City Hospital, Taipei City, Taiwan
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Ramesh K, Srinivasan G, Bidkar PU. Comparison of Tracheal Intubation Using King Vision (Non-channeled Blade) and Tuoren Video Laryngoscopes in Patients With Cervical Spine Immobilization by Manual In-Line Stabilization: A Randomized Clinical Trial. Cureus 2023; 15:e43471. [PMID: 37711910 PMCID: PMC10499184 DOI: 10.7759/cureus.43471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Glottic visualization on cervical immobilization with manual in-line stabilization (MILS) might be challenging in individuals with cervical spine injuries. We compared non-channeled King Vision video laryngoscope (VL) (Ambu GmbH, Bad Nauheim, Germany) with Tuoren video laryngoscope (Henan Tuoren Medical Device, Zhengzhou, China) for endotracheal intubation in patients with cervical spine immobilization. METHODS A total of 124 patients undergoing elective surgery under general anesthesia were included in this study. After induction of general anesthesia, patients were randomized into two groups (62 each): group K (non-channeled blade of King Vision video laryngoscope) and group T (Tuoren video laryngoscope). Cervical spine immobilization was achieved with manual in-line stabilization. The success of the first pass intubation, the time required to intubate, glottic visualization, and intubation difficulty score (IDS) were recorded. RESULTS The first-attempt success rate of intubation was 95.2% (59 out of 62 patients) in group K and 90.3% (56 out of 62 patients) in group T, which were comparable. The mean glottic visualization time was significantly less with group T (12.74 ± 6.32 seconds) compared to group K (17.92 ± 4.24 seconds). Intubation time was significantly faster with group K (18.79 ± 5.857 seconds) compared to group T (27.21 ± 8.514 seconds). Both video laryngoscopes provided good grades of glottic visualization. CONCLUSIONS We conclude that the performance of the Tuoren video laryngoscope is similar to the King Vision video laryngoscope in terms of first-attempt intubation success rate and glottic visualization score in patients with cervical spine immobilization by manual in-line stabilization. Although glottic visualization time was shorter with Tuoren VL, we could achieve faster intubation with King Vision VL.
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Affiliation(s)
- Killo Ramesh
- Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Gnanasekaran Srinivasan
- Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Prasanna U Bidkar
- Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
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Behari D, Jaga R, Bergh K, Hofmeyr R. Intubation during spinal motion restriction using the LuboTM cervical collar - a manikin simulation study. Afr J Emerg Med 2022; 12:327-332. [PMID: 35919101 PMCID: PMC9334326 DOI: 10.1016/j.afjem.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 05/12/2022] [Accepted: 06/24/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction The LuboTM collar is a cervical motion restriction device featuring a unique external jaw-thrust mechanism designed to provide non-invasive airway patency. In addition, tracheal intubation is facilitated by releasing an anterior chin strap; this allows better mouth opening than the previous generation of semi-rigid cervical collars. This study aimed to compare tracheal intubation using the LuboTM collar combined with manual in-line stabilization (MILS) to intubation with MILS alone. The primary outcome was the time to successful intubation. Secondary outcomes compared intubation success rate, Cormack-Lehane grade, ease of intubation and dental trauma. Methods A randomized, cross-over, equivalence study was performed. Eighty full-time physician anaesthesia providers were recruited. Participants performed tracheal intubation using direct laryngoscopy on a manikin under two different scenarios: with the LuboTM collar and MILS applied, and with MILS and no cervical collar. The time to successful intubation was measured and compared using two-one-sided and paired t-tests. Results Intubation times fell well within the a priori equivalence limits of 10 seconds, with a mean difference (95% CI) of 0.52 seconds (-1.30 to 2.56). There was no significant difference in intubation time with the LuboTM collar (mean [SD] 19.2 [4.5] seconds) compared to the MILS alone group (19.7 [5.2] seconds). The overall success rate was 98.7% in the Lubo group and 100% in the MILS group. Adequate laryngoscopy views (Cormack-Lehane grades I to IIb) were equivalent between groups (Lubo 92.5% versus MILS alone 93.7%). Conclusion In this manikin-based study, the time to intubation with the LuboTM collar and MILS applied was equivalent to time to intubation with MILS alone, with similar intubating conditions. Thus, the LuboTM collar and MILS may simplify airway management by reducing the number of steps required to perform intubation in patients requiring cervical motion restriction.
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The Use of the Shikani Video-Assisted Intubating Stylet Technique in Patients with Restricted Neck Mobility. Healthcare (Basel) 2022; 10:healthcare10091688. [PMID: 36141300 PMCID: PMC9498386 DOI: 10.3390/healthcare10091688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/01/2022] [Accepted: 09/01/2022] [Indexed: 11/17/2022] Open
Abstract
Among all the proposed predictors of difficult intubation defined by the intubation difficulty scale, head and neck movement (motility) stands out and plays as a crucial factor in determining the success rate and the degree of ease on endotracheal intubation. Aside from other airway tools (e.g., supraglottic airway devices), optical devices have been developed and applied for more than two decades and have shown their superiority to conventional direct laryngoscopes in many clinical scenarios and settings. Although awake/asleep flexible fiberoptic bronchoscopy is still the gold standard in patients with unstable cervical spines immobilized with a rigid cervical collar or a halo neck brace, videolaryngoscopy has been repeatedly demonstrated to be advantageous. In this brief report, for the first time, we present our clinical experience on the routine use of the Shikani video-assisted intubating stylet technique in patients with traumatic cervical spine injuries immobilized with a cervical stabilizer and in a patient with a stereotactic headframe for neurosurgery. Some trouble-shooting strategies for this technique are discussed. This paper demonstrates that the video-assisted intubating stylet technique is an acceptable alternative airway management method in patients with restricted or confined neck motility.
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Hansel J, Rogers AM, Lewis SR, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation. Cochrane Database Syst Rev 2022; 4:CD011136. [PMID: 35373840 PMCID: PMC8978307 DOI: 10.1002/14651858.cd011136.pub3] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
| | - Andrew M Rogers
- Department of Anaesthesia, Royal United Hospitals Bath NHS Trust, Bath, UK
| | - Sharon R Lewis
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Tim M Cook
- Department of Anaesthesia, Royal United Hospitals Bath NHS Trust, Bath, UK
- University of Bristol, Bristol, UK
| | - Andrew F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
- Lancaster University, Lancaster, 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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Nam K, Lee Y, Park HP, Chung J, Yoon HK, Kim TK. Cervical Spine Motion During Tracheal Intubation Using an Optiscope Versus the McGrath Videolaryngoscope in Patients With Simulated Cervical Immobilization: A Prospective Randomized Crossover Study. Anesth Analg 2019; 129:1666-1672. [PMID: 31743188 DOI: 10.1213/ane.0000000000003635] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND In patients with an unstable cervical spine, maintenance of cervical immobilization during tracheal intubation is important. In McGrath videolaryngoscopic intubation, lifting of the blade to raise the epiglottis is needed to visualize the glottis, but in patients with an unstable cervical spine, this can cause cervical spine movement. By contrast, the Optiscope, a rigid video-stylet, does not require raising of the epiglottis during tracheal intubation. We therefore hypothesized that the Optiscope would produce less cervical spine movement than the McGrath videolaryngoscope during tracheal intubation. The aim of this study was to compare the Optiscope with the McGrath videolaryngoscope with respect to cervical spine motion during intubation in patients with simulated cervical immobilization. METHODS The primary outcome of the study was the extent of cervical spine motion at the occiput-C1, C1-C2, and C2-C5 segments. In this randomized crossover study, the cervical spine angle was measured before and during tracheal intubation using either the Optiscope or the McGrath videolaryngoscope in 21 patients with simulated cervical immobilization. Cervical spine motion was defined as the change in angle at each cervical segment during tracheal intubation. RESULTS There was significantly less cervical spine motion at the occiput-C1 segment using the Optiscope rather than the McGrath videolaryngoscope (mean [98.33% CI]: 4.7° [2.4-7.0] vs 10.4° [8.1-12.7]; mean difference [98.33% CI]: -5.7° [-7.5 to -3.9]). There were also fewer cervical spinal motions at the C1-C2 and C2-C5 segments using the Optiscope (mean difference versus the McGrath videolaryngoscope [98.33% CI]: -2.4° [-3.7 to -1.2]) and -3.7° [-5.9 to -1.4], respectively). CONCLUSIONS The Optiscope produces less cervical spine motion than the McGrath videolaryngoscope during tracheal intubation of patients with simulated cervical immobilization.
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Affiliation(s)
- Karam Nam
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Younsuk Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Medical Center Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Hee-Pyoung Park
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jaeyeon Chung
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Kyu Yoon
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Tae Kyong Kim
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Eberlein CM, Luther IS, Carpenter TA, Ramirez LD. First-Pass Success Intubations Using Video Laryngoscopy Versus Direct Laryngoscopy: A Retrospective Prehospital Ambulance Service Study. Air Med J 2019; 38:356-358. [PMID: 31578974 DOI: 10.1016/j.amj.2019.06.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/14/2019] [Accepted: 06/13/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE In emergency medicine, endotracheal intubation is the gold standard for airway management. First-pass intubation success is beneficial because it secures the patient airway more quickly and avoids complications associated with repeated attempts, such as bleeding and swelling of soft tissue. The key to first-pass success is the ability to visualize the laryngeal inlet. Visualization can be accomplished using traditional direct laryngoscopy or video laryngoscopy. The purpose of our study was to compare the rate of successful first-pass endotracheal intubations using a video laryngoscope with that using a direct visualization laryngoscope in a prehospital emergency setting. METHODS We retrospectively reviewed data that had been prospectively collected in our emergency department regarding patients who underwent endotracheal intubation performed by personnel from a single local ambulance service from January 1, 2014, through December 31, 2015. RESULTS One hundred eighty-one patients were intubated using video laryngoscopy and 115 using direct visualization laryngoscopy. The first-pass endotracheal intubation success rate using video laryngoscopy was 12.6% higher than with direct laryngoscopy. CONCLUSION This retrospective study shows that video laryngoscopy had a higher first-pass success rate than direct laryngoscopy. This is promising because decreasing failure rates provide better patient outcomes.
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Affiliation(s)
| | - Isidora S Luther
- Department of Emergency Medicine, Gundersen Health System, La Crosse, WI.
| | - Tom A Carpenter
- Department of Emergency Medical Services, Gundersen Health System, La Crosse, WI
| | - Luis D Ramirez
- Department of Medical Research, Gundersen Health System, La Crosse, WI
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Abdallah SI, Gaballah KM. Endotracheal Intubation Criteria and Stress Response: Airtraq versus Macintosh Laryngoscopes - A Prospective Randomized Controlled Trial. Anesth Essays Res 2019; 13:430-436. [PMID: 31602057 PMCID: PMC6775823 DOI: 10.4103/aer.aer_80_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: Airtraq® is a single-use video laryngoscope used to facilitate tracheal intubation in both expected and unexpected difficult airways. Aims: We hypothesized that Airtraq laryngoscope would facilitate better intubation criteria and lower stress response to laryngoscopy in comparison to the Macintosh laryngoscope. Materials and Methods: In this randomized, single-blinded, prospective study, 70 adult patients were randomly assigned to be intubated with either Airtraq (Group AT) or Macintosh (Group M) laryngoscope (35 patients in each). The primary outcomes involved intubation time, first-attempt success rate, time to best laryngoscopic view, and percentage of glottic opening (POGO) score. Other recorded parameters involved the hemodynamic and intraocular pressure (IOP) responses to laryngoscopy and intubation and complications during and after laryngoscopy and after extubation. Serum samples were collected before anesthesia induction and 2 min after intubation and analyzed for epinephrine, cortisol, and glucose. Results: Group AT had significantly higher POGO score and significantly shorter intubation time and time to best laryngoscopic view than Group M (P < 0.001). The first-attempt success rate was 97.1% in Group AT and 94.3% in Group M (P = 0.55). Postoperatively, laryngospasm and sore throat were encountered in 2.9% of Group M patients compared to 0% in Group AT (P = 1.00). The heart rate, mean arterial pressure, IOP, serum epinephrine, and cortisol were significantly increased in Group M than Group AT. Conclusion: In comparison to the Macintosh laryngoscope, Airtraq conferred significantly better intubation criteria and lesser stress response to laryngoscopy and intubation.
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Affiliation(s)
- Sabry Ibrahim Abdallah
- Department of Anaesthesiology, Faculty of Medicine, Menoufia University, Al Minufiyah, Egypt
| | - Khaled Mohamed Gaballah
- Department of Anaesthesiology, Faculty of Medicine, Menoufia University, Al Minufiyah, Egypt
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Comparison between Glidescope, Airtraq and Macintosh laryngoscopy for emergency endotracheal intubation in intensive care unit: Randomized controlled trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2018.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Chou C, Snyderman C, Phillips D, Darby J. The Difficult Airway after Endoscopic Endonasal Skull Base Surgery: A Case Series and Management Algorithm. Otolaryngol Head Neck Surg 2018; 159:927-932. [PMID: 30081764 DOI: 10.1177/0194599818789099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To analyze difficult airway situations affecting patients after endoscopic endonasal surgery (EES) for skull base tumors and to develop an airway management algorithm. STUDY DESIGN Case series with chart review. SETTING Single tertiary care center. SUBJECTS AND METHODS Eleven difficult airway events occurred among patients after EES for skull base tumors, as identified through a retrospective review of our institutional Difficult Airway Management Team registry from January 2008 to March 2016. Data from these events included patient demographics, event characteristics, airway management techniques, and outcomes. Results were used to design a difficult airway protocol. RESULTS The majority of patients were obese (63.6%) and had a dural defect (90.9%), each of which was repaired with a vascularized flap. The most common reasons for the difficult airway call were concern for using mask ventilation in a patient with a dural defect (27.3%) and difficult airway anatomy (27.3%). Two patients did not require airway intervention; 8 were intubated; and 1 underwent cricothyroidotomy. Videolaryngoscopy was the most common first-attempt intubation technique, followed by conventional direct laryngoscopy. Effective adjunctive techniques included intubation through a laryngeal mask airway and bougie-guided intubation. As compared with simple mask ventilation, laryngeal mask airway-assisted ventilation was associated with a decreased incidence of postevent cerebrospinal fluid leak. There were no incidences of postevent pneumocephalus, cardiopulmonary arrest, or mortality. CONCLUSIONS We propose a difficult airway algorithm for patients following EES of the skull base, with sequential recommendations for airway management methods and commentary on adjunctive techniques.
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Affiliation(s)
- Courtney Chou
- 1 Department of Otolaryngology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Carl Snyderman
- 1 Department of Otolaryngology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dennis Phillips
- 2 Department of Anesthesiology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,3 Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joseph Darby
- 3 Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Hoshijima H, Maruyama K, Mihara T, Mieda T, Shiga T, Nagasaka H. Airtraq® reduces the hemodynamic response to tracheal intubation using single-lumen tubes in adults compared with the Macintosh laryngoscope: A systematic review and meta-analysis of randomized control trials. J Clin Anesth 2018; 47:86-94. [PMID: 29635148 DOI: 10.1016/j.jclinane.2018.03.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 03/21/2018] [Accepted: 03/22/2018] [Indexed: 12/27/2022]
Abstract
STUDY OBJECTIVE To investigate whether Airtraq® attenuate the hemodynamic responses to tracheal intubation using single-lumen tubes in adults as compared with the Macintosh laryngoscope. DESIGN Meta-analysis. SETTING Operating room. MEASUREMENTS The primary outcome of this meta-analysis was to determine whether laryngoscopy using the Airtraq® reduced hemodynamic responses-heart rate (HR) and mean blood pressure (MBP)-at 60 s (s) after tracheal intubation compared to laryngoscopy with the Macintosh laryngoscope. Pooled differences in these hemodynamic responses between the two devices were expressed as weighted mean difference with 95% confidence intervals. We then conducted trial sequential analysis (TSA). The secondary outcome was to investigate whether the Airtraq® reduce the hemodynamic response at 120 s, 180 s, and 300 s after tracheal intubation compared to the Macintosh laryngoscope. We also conducted sensitivity analysis of the hemodynamic responses to tracheal intubation with the laryngoscopes using a multivariate random effects model accounting for within-study correlation of the longitudinal data. MAIN RESULTS From electronic databases, we selected 11 randomized controlled trials for studies that enrolled subjects satisfying our inclusion criteria. Compared with the Macintosh laryngoscope, the Airtraq® significantly reduced both HR and MBP at 60 s after tracheal intubation. In secondary outcome, the Airtraq® significantly reduced both HR and MBP at all measurement points, excluding HR at 300 s after tracheal intubation. TSA showed that total sample size reached the required information size for both HR and MBP. The sensitivity analysis revealed that the Airtraq® reduced both HR and MBP at all measurement points, excluding HR at 300 s after tracheal intubation. CONCLUSIONS The Airtraq® attenuates the hemodynamic response at 60 s after tracheal intubation compared with the Macintosh laryngoscope. (GRADE: Low) These results were supported by the sensitivity analysis. TSA suggested that the total sample size was exceeded TSA monitoring boundary both HR and MBP.
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Affiliation(s)
- Hiroshi Hoshijima
- Department of Anesthesiology, Saitama Medical University Hospital, Moroyama, Saitama 350-0495, Japan.
| | - Koichi Maruyama
- Department of Anesthesiology, University Hospital Mizonokuchi, Teikyo University School of Medicine, Kawasaki, Kanagawa 213-8507, Japan
| | - Takahiro Mihara
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa 236-0004, Japan
| | - Tsutomu Mieda
- Department of Anesthesiology, Saitama Medical University Hospital, Moroyama, Saitama 350-0495, Japan
| | - Toshiya Shiga
- Department of Anesthesiology and Intensive Care Medicine, International University of Health and Welfare, School of Medicine, Ichikawa, Chiba 286-8686, Japan
| | - Hiroshi Nagasaka
- Department of Anesthesiology, Saitama Medical University Hospital, Moroyama, Saitama 350-0495, Japan
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Hazarika H, Saxena A, Meshram P, Kumar Bhargava A. A randomized controlled trial comparing C Mac D Blade and Macintosh laryngoscope for nasotracheal intubation in patients undergoing surgeries for head and neck cancer. Saudi J Anaesth 2018; 12:35-41. [PMID: 29416454 PMCID: PMC5789504 DOI: 10.4103/sja.sja_239_17] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Purpose Several devices are available to take care of difficult airway, but C-MAC D-Blade has scant evidence of its use in nasotracheal intubation in a difficult airway scenario. Aims and Objectives We compared the C-MAC D-Blade videolaryngoscope™, and the standard Macintosh laryngoscope for nasal intubation in patients with difficult airways selected by El-Ganzouri risk index using parameters of time and attempts required for intubation, glottic view in terms of Cormack-Lehane grade, ease of intubation, success rate, use of accessory maneuvers, incidence of complications, and hemodynamic changes. Methods One hundred American Society of Anesthesiologists (ASA) I-III patients aged 20-70 years with EGRI score 1-≤7 scheduled for head and neck surgery requiring nasal intubation. ASA IV patients, patients with mouth opening <2.5 cm, patients difficult to mask ventilate, and patients with hyperkalemia and history of malignant hyperthermia were excluded from the study. Primary outcome was time taken to intubation, and secondary outcomes were a number of attempts, glottic view in terms of C/L grade, use of accessory maneuvers, success rate, incidence of trauma, ease of intubation, and hemodynamic changes before and after intubation. Results Time required for intubation was less (39.56 ± 15.65 s) in Group C than in Group M (50.34 ± 15.65 s). Cormack-Lehane Grade I and II view were more in C-MAC D-Blade group (P < 0.05). Success rate and ease of intubation were found to be more in C-MAC D-Blade group than in Macintosh group (P < 0.05). A number of attempts and incidence of complications such as trauma, bleeding, and failed intubation were greater in Macintosh group than in C-MAC D-Blade group. Hemodynamic changes were observed to be comparable in both the groups. Conclusion C-MAC D-Blade videolaryngoscope™ is a better tool in anesthetic management of difficult airway for nasal intubation compared to conventional Macintosh laryngoscope.
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Affiliation(s)
- Hrishikesh Hazarika
- Department of Anesthesiology, Rajiv Gandhi Cancer Institute and Research Centre, Sector V, Rohini, New Delhi, India
| | - Anudeep Saxena
- Department of Anesthesiology, Rajiv Gandhi Cancer Institute and Research Centre, Sector V, Rohini, New Delhi, India
| | - Pradeep Meshram
- Department of Anesthesiology, Rajiv Gandhi Cancer Institute and Research Centre, Sector V, Rohini, New Delhi, India
| | - Ajay Kumar Bhargava
- Department of Anesthesiology, Rajiv Gandhi Cancer Institute and Research Centre, Sector V, Rohini, New Delhi, India
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14
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Eismann H, Sieg L, Etti N, Friedrich L, Schröter C, Mommsen P, Krettek C, Zeckey C. Improved success rates using videolaryngoscopy in unexperienced users: a randomized crossover study in airway manikins. Eur J Med Res 2017; 22:27. [PMID: 28797305 PMCID: PMC5553664 DOI: 10.1186/s40001-017-0268-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 07/29/2017] [Indexed: 12/05/2022] Open
Abstract
Background Videolaryngoscopy has been proven to be a safe procedure managing difficult airways in the hands of airway specialists. Information about the success rates in unexperienced users of videolaryngoscopy compared to conventional laryngoscopy is sparse. Therefore, we aimed to evaluate if there might be more success in securing an airway if the unexperienced provider is using a videolaryngoscope in simulated airways in a randomized manikin study. Differences between commonly used videolaryngoscopes were elucidated. Methods A standardized hands-on workshop prior to the study was performed. For direct laryngoscopy (DL) we used a Macintosh laryngoscope, whereas for videolaryngoscopy (VL) we used the cMac, the dBlade, and a King Vision videolaryngoscope. Endotracheal intubations in three simulated normal and difficult airways were performed. Main outcome parameters were time to view and time to intubation. Cormack and Lehane (C + L) classification and the percentage of glottic opening (POGO) score were evaluated. After every intubation, the participants were asked to review the airway and the device used. Results 22 participants (14.8 ± 4.0 intubations per year, mostly trauma surgeons) with limited experience in videolaryngoscopy (mean total number of videolaryngoscopy .4 ± .2) were enrolled. We found improved C + L grades with VL in contrast to DL. We saw similar data with respect to the POGO score, where the participants achieved better visibility of the glottis with VL. The hyperangulated blade geometries of videolaryngoscopes provided a better visibility in difficult airways than the standard geometry of the Macintosh-type blade. The subjective performance of the VL devices was better in more difficult airway scenarios. Conclusions After a short introduction and hands-on training, a videolaryngoscope seems to be safe and usable by unexperienced providers. We assume a standard geometry laryngoscope is optimal for a patient with normal anatomy, whereas VL device with a hyperangulated blade is ideal for difficult airway situations with limited mouth opening or restricted neck movement.
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Affiliation(s)
- Hendrik Eismann
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Lion Sieg
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Nicola Etti
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Lars Friedrich
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Christian Schröter
- Trauma Department, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Philipp Mommsen
- Trauma Department, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Christian Krettek
- Trauma Department, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Christian Zeckey
- Trauma Department, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany. .,Department of General-, Trauma- and Reconstructive Surgery, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, Munich, Germany.
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15
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Hosalli V, Arjun BK, Ambi U, Hulakund S. Comparison of Airtraq™, McCoy™ and Macintosh laryngoscopes for endotracheal intubation in patients with cervical spine immobilisation: A randomised clinical trial. Indian J Anaesth 2017; 61:332-337. [PMID: 28515522 PMCID: PMC5416724 DOI: 10.4103/ija.ija_517_16] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background and Aims: The study aimed at comparing the performance of the novel optical Airtraq™ laryngoscope with the McCoy™ and conventional Macintosh laryngoscopes for ease of endotracheal intubation in patients with neck immobilisation using manual inline axial cervical spine stabilisation (MIAS) technique. Methods: Ninety consenting American Society of Anaesthesiologist's physical status I–II patients, aged 18–60 years, scheduled for various surgeries requiring tracheal intubation were randomly assigned into three groups of thirty each to undergo intubation with Macintosh, Airtraq™, or McCoy™ laryngoscope with neck immobilisation by MIAS technique. The ease of intubation based on Intubation difficulty scale (IDS) score, Cormack-Lehane grade of glottic view, optimisation manoeuvres and impact on haemodynamic parameters were recorded. Statistical analysis was performed with ANOVA and Bonferroni correction for post hoc tests. Results: All patients in three groups had a comparable demographic profile and were successfully intubated. The Airtraq™ laryngoscope significantly reduced the IDS (mean − 0.43 ± 0.81) as compared with both McCoy™ (mean − 1.63 ± 1.49, P = 0.001) and Macintosh laryngoscope (mean −2.23 ± 1.92, P < 0.001) and improved the Cormack-Lehane glottic view (77% grade 1 view and no patients with grade 3 or 4 view). There were less haemodynamic variations during laryngoscopy with the Airtraq™ compared to the Macintosh laryngoscope, but there was not between the Airtraq™ and McCoy™ laryngoscope groups. Conclusion: In patients undergoing endotracheal intubation with cervical immobilisation, Airtraq™ laryngoscope was superior to the McCoy™ and Macintosh laryngoscopes, with greater ease of intubation and lower impact on haemodynamic variables.
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Affiliation(s)
- Vinod Hosalli
- S Nijalingappa Medical College, Hanagal Shree Kumareshwar Hospital and Research Center, Bagalkot, Karnataka, India
| | - B K Arjun
- S Nijalingappa Medical College, Hanagal Shree Kumareshwar Hospital and Research Center, Bagalkot, Karnataka, India
| | - Uday Ambi
- S Nijalingappa Medical College, Hanagal Shree Kumareshwar Hospital and Research Center, Bagalkot, Karnataka, India
| | - Shivanand Hulakund
- S Nijalingappa Medical College, Hanagal Shree Kumareshwar Hospital and Research Center, Bagalkot, Karnataka, India
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16
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Lewis SR, Butler AR, Parker J, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation. Cochrane Database Syst Rev 2016; 11:CD011136. [PMID: 27844477 PMCID: PMC6472630 DOI: 10.1002/14651858.cd011136.pub2] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Successful tracheal intubation during general anaesthesia traditionally requires a line of sight to the larynx attained by positioning the head and neck and using a laryngoscope to retract the tongue and soft tissues of the floor of the mouth. Difficulties with intubation commonly arise, and alternative laryngoscopes that use digital and/or fibreoptic technology have been designed to improve visibility when airway difficulty is predicted or encountered. Among these devices, a rigid videolaryngoscope (VLS) uses a blade to retract the soft tissues and transmits a lighted video image to a screen. OBJECTIVES Our primary objective was to assess whether use of videolaryngoscopy for tracheal intubation in adults requiring general anaesthesia reduces risks of complications and failure compared with direct laryngoscopy. Our secondary aim was to assess the benefits and risks of these devices in selected population groups, such as adults with obesity and those with a known or predicted difficult airway. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase on 10 February 2015. Our search terms were relevant to the review question and were not limited by outcomes. We carried out clinical trials register searches and forward and backward citation tracking. We reran the search on 12 January 2016; we added potential new studies of interest from the 2016 search to a list of 'Studies awaiting classification', and we will incorporate these studies into the formal review during the review update. SELECTION CRITERIA We considered all randomized controlled trials and quasi-randomized studies with adult patients undergoing laryngoscopy performed with a VLS or a Macintosh laryngoscope in a clinical, emergency or out-of-hospital setting. We included parallel and cross-over study designs. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data, consulting a third review author to resolve disagreements. We used standard Cochrane methodological procedures, including assessment of risk of bias. MAIN RESULTS We included 64 studies identified during the 2015 search that enrolled 7044 adult participants and compared a VLS of one or more designs with a Macintosh laryngoscope. We identified 38 studies awaiting classification and seven ongoing studies. Of the 64 included studies, 61 included elective surgical patients, and three were conducted in an emergency setting. Among 48 studies that included participants without a predicted difficult airway, 15 used techniques to simulate a difficult airway. Seven recruited participants with a known or predicted difficult airway, and the remaining studies did not specify or included both predicted and not predicted difficult airways. Only two studies specifically recruited obese participants. It was not possible to blind the intubator to the device, and we noted a high level of inevitable heterogeneity, given the large number of studies.Statistically significantly fewer failed intubations were reported when a VLS was used (Mantel-Haenszel (M-H) odds ratio (OR), random-effects 0.35, 95% confidence Interval (CI) 0.19 to 0.65; 38 studies; 4127 participants), and fewer failed intubations occurred when a VLS was used in participants with an anticipated difficult airway (M-H OR, random-effects 0.28, 95% CI 0.15 to 0.55; six studies; 830 participants). We graded the quality of this evidence as moderate on the basis of the GRADE system. Failed intubations were fewer when a VLS was used in participants with a simulated difficult airway (M-H OR, random-effects 0.18, 95% CI 0.04 to 0.77; nine studies; 810 participants), but groups with no predicted difficult airway provided no significant results (M-H OR, random-effects 0.61, 95% CI 0.22 to 1.67; 19 studies; 1743 participants).Eight studies reported on hypoxia, and only three of these described any events; results showed no differences between devices for this outcome (M-H OR, random-effects 0.39, 95% CI 0.10 to 1.44; 1319 participants). Similarly, few studies reported on mortality, noting no differences between devices (M-H OR, fixed-effect 1.09, 95% CI 0.65 to 1.82; two studies; 663 participants), and only one study reporting on the occurrence of respiratory complications (78 participants); we graded these three outcomes as very low quality owing to lack of data. We found no statistically significant differences between devices in the proportion of successful first attempts (M-H OR, random-effects 1.27, 95% CI 0.77 to 2.09; 36 studies; 4731 participants) nor in those needing more than one attempt. We graded the quality of this evidence as moderate. Studies reported no statistically significant differences in the incidence of sore throat in the postanaesthesia care unit (PACU) (M-H OR, random-effects 1.00 (95% CI 0.73 to 1.38); 10 studies; 1548 participants) nor at 24 hours postoperatively (M-H OR random-effects 0.54, 95% CI 0.27 to 1.07; eight studies; 844 participants); we graded the quality of this evidence as moderate. Data combined to include studies of cross-over design revealed statistically significantly fewer laryngeal or airway traumas (M-H OR, random-effects 0.68, 95% CI 0.48 to 0.96; 29 studies; 3110 participants) and fewer incidences of postoperative hoarseness (M-H OR, fixed-effect 0.57, 95% CI 0.36 to 0.88; six studies; 527 participants) when a VLS was used. A greater number of laryngoscopies performed with a VLS achieved a view of most of the glottis (M-H OR, random-effects 6.77, 95% CI 4.17 to 10.98; 22 studies; 2240 participants), fewer laryngoscopies performed with a VLS achieved no view of the glottis (M-H OR, random-effects 0.18, 95% CI 0.13 to 0.27; 22 studies; 2240 participants) and the VLS was easier to use (M-H OR, random-effects 7.13, 95% CI 3.12 to 16.31; seven studies; 568 participants).Although a large number of studies reported time required for tracheal intubation (55 studies; 6249 participants), we did not present an effects estimate for this outcome owing to the extremely high level of statistical heterogeneity (I2 = 96%). AUTHORS' CONCLUSIONS Videolaryngoscopes may reduce the number of failed intubations, particularly among patients presenting with a difficult airway. They improve the glottic view and may reduce laryngeal/airway trauma. Currently, no evidence indicates that use of a VLS reduces the number of intubation attempts or the incidence of hypoxia or respiratory complications, and no evidence indicates that use of a VLS affects time required for intubation.
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Affiliation(s)
- Sharon R Lewis
- Patient Safety Research Department, Royal Lancaster Infirmary, Pointer Court 1, Ashton Road, Lancaster, UK, LA1 1RP
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Ertürk T, Deniz S, Şimşek F, Purtuloğlu T, Kurt E. Comparison of the Macintosh and Airtraq Laryngoscopes in Endotracheal Intubation Success. Turk J Anaesthesiol Reanim 2016; 43:181-7. [PMID: 27366492 DOI: 10.5152/tjar.2015.38278] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 09/29/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Endotracheal intubation of patients is an effective method for controlling airway and breathing. However, laryngoscopy and endotracheal intubation is not easy in every case. There is a recent abundance of equipment used for controlling ventilation and intubation. Airtraq is one of those equipments. In this study, our main objective is to compare the success rates of the Airtraq and Macintosh (direct and classic) laryngoscopes in endotracheal intubation. METHODS In this single-center, prospective, randomized, clinical study was performed on 80 patients who were operated under general anesthesia, ASA I-II, 18-65 years old. Patients were intubated using two different endotracheal intubation tools. Group A was intubated using the Macintosh (direct and classic) laryngoscope, meanwhile Group B was intubated using the Airtraq laryngoscope. Patients' snoring complaints, modified Mallampati scores, sternomental distances, thyromental distances, interincisor distance measurements and Cormack-Lehane (C-L) laryngoscopic classification, upper lip bite test results, intubation time, number of intubation attempts, maneuvers and techniques used for facilitating intubation and complications arising from intubation were recorded. RESULTS There was a statistically significant difference between the groups in terms of C-L scores (p=0.041). In all, 8 patients in the Macintosh group, and 2 patients in the Airtraq group were C-L grade III. In intubation of the Airtraq group, only 3 patients required facilitating techniques, meanwhile in intubation of the Macintosh group 15 patients we had to use one or more facilitating maneuver. The rate of Mallampati scoring "difficult" was 4/6 in the Macintosh and 2/11 in Airtraq laryngoscopy groups (p=0.553). CONCLUSION In cases with seemingly difficult intubations, we believe the Airtraq laryngoscope has an advantage over the Macintosh laryngoscope, owing to its better view of the oropharyngeal and glottic areas in addition to facilitating intubation in patients with limited head extension.
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Affiliation(s)
- Tuna Ertürk
- Department of Anaesthesiology and Reanimation, Gülhane Military Medical Academy, Ankara, Turkey
| | - Süleyman Deniz
- Department of Anaesthesiology and Reanimation, Gülhane Military Medical Academy Haydarpaşa Training Hospital, İstanbul, Turkey
| | - Fatih Şimşek
- Department of Anaesthesiology and Reanimation, Ardahan Military Hospital, Ardahan, Turkey
| | - Tarık Purtuloğlu
- Department of Anaesthesiology and Reanimation, Gülhane Military Medical Academy, Ankara, Turkey
| | - Ercan Kurt
- Department of Anaesthesiology and Reanimation, Gülhane Military Medical Academy, Ankara, Turkey
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18
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Suppan L, Tramèr MR, Niquille M, Grosgurin O, Marti C. Alternative intubation techniques vs Macintosh laryngoscopy in patients with cervical spine immobilization: systematic review and meta-analysis of randomized controlled trials. Br J Anaesth 2015; 116:27-36. [PMID: 26133898 PMCID: PMC4681615 DOI: 10.1093/bja/aev205] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2015] [Indexed: 02/06/2023] Open
Abstract
Background. Immobilization of the cervical spine worsens tracheal intubation conditions. Various intubation devices have been tested in this setting. Their relative usefulness remains unclear. Methods. We searched MEDLINE, EMBASE, and the Cochrane Library for randomized controlled trials comparing any intubation device with the Macintosh laryngoscope in human subjects with cervical spine immobilization. The primary outcome was the risk of tracheal intubation failure at the first attempt. Secondary outcomes were quality of glottis visualization, time until successful intubation, and risk of oropharyngeal complications. Results. Twenty-four trials (1866 patients) met inclusion criteria. With alternative intubation devices, the risk of intubation failure was lower compared with Macintosh laryngoscopy [risk ratio (RR) 0.53; 95% confidence interval (CI) 0.35–0.80]. Meta-analyses could be performed for five intubation devices (Airtraq, Airwayscope, C-Mac, Glidescope, and McGrath). The Airtraq was associated with a statistically significant reduction of the risk of intubation failure at the first attempt (RR 0.14; 95% CI 0.06–0.33), a higher rate of Cormack–Lehane grade 1 (RR 2.98; 95% CI 1.94–4.56), a reduction of time until successful intubation (weighted mean difference −10.1 s; 95% CI −3.2 to −17.0), and a reduction of oropharyngeal complications (RR 0.24; 95% CI 0.06–0.93). Other devices were associated with improved glottis visualization but no statistically significant differences in intubation failure or time to intubation compared with conventional laryngoscopy. Conclusions. In situations where the spine is immobilized, the Airtraq device reduces the risk of intubation failure. There is a lack of evidence for the usefulness of other intubation devices.
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Affiliation(s)
- L Suppan
- Division of Emergency Medicine, Geneva University Hospitals, rue Gabrielle-Perret-Gentil 2, CH-1211 Geneva 14, Switzerland
| | - M R Tramèr
- Division of Anaesthesiology, Geneva University Hospitals, Geneva, Switzerland Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - M Niquille
- Division of Emergency Medicine, Geneva University Hospitals, rue Gabrielle-Perret-Gentil 2, CH-1211 Geneva 14, Switzerland
| | - O Grosgurin
- Division of Emergency Medicine, Geneva University Hospitals, rue Gabrielle-Perret-Gentil 2, CH-1211 Geneva 14, Switzerland
| | - C Marti
- Division of Emergency Medicine, Geneva University Hospitals, rue Gabrielle-Perret-Gentil 2, CH-1211 Geneva 14, Switzerland
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19
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Bhandari G, Shahi KS, Asad M, Bhakuni R. Airtraq(®) versus Macintosh laryngoscope: A comparative study in tracheal intubation. Anesth Essays Res 2015; 7:232-6. [PMID: 25885839 PMCID: PMC4173514 DOI: 10.4103/0259-1162.118971] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background: The curved laryngoscope blade described by Macintosh in 1943 remains the most widely used device to facilitate tracheal intubation. The Airtraq® (Prodol Meditec S.A, Vizcaya, Spain) is a new, single use, indirect laryngoscope introduced into clinical practice in 2005. It has wan exaggerated blade curvature with internal arrangement of optical lenses and a mechanism to prevent fogging of the distal lens. A high quality view of the glottis is provided without the need to align the oral, pharyngeal and tracheal axis. We evaluated Airtraq and Macintosh laryngoscopes for success rate of tracheal intubation, overall duration of successful intubation, optimization maneuvers, POGO (percentage of glottic opening) score, and ease of intubation. Materials and Methods: Patients were randomly allocated by computer-generated random table to one of the two groups, comprising 40 patients each, group I (Airtraq) and group II (Macintosh). After induction of general anesthesia, tracheal intubation was attempted with the Airtraq or the Macintosh laryngoscope as per group. Primary end points were overall success rate of tracheal intubation, overall duration of successful tracheal intubation, optimization maneuvers, POGO score and ease of intubation between the two groups. Results: We observed that Airtraq was better than the Macintosh laryngoscope as duration of successful intubation was shorter in Airtraq 18.15 seconds (±2.74) and in the Macintosh laryngoscope it was 32.72 seconds (±8.31) P < 0.001. POGO was also better in the Airtraq group 100% grade 1 versus 67.5% in the Macintosh group, P < 0.001. Ease of intubation was also better in the Airtraq group. It was easy in 97.5% versus 42.5% in the Macintosh group, P < 0.001. Conclusion: Both Airtraq and Macintosh laryngoscopes are equally effective in tracheal intubation in normal airways. Duration of successful tracheal intubation was shorter in the Airtraq group which was statistically significant.
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Affiliation(s)
- Geeta Bhandari
- Department of Anesthesiology, Govt. Medical College, Haldwani (Nainital), Uttarakhand, India
| | - K S Shahi
- Department of Surgery, Govt. Medical College, Haldwani (Nainital), Uttarakhand, India
| | - Mohammad Asad
- Department of Anesthesiology, Govt. Medical College, Haldwani (Nainital), Uttarakhand, India
| | - Rajani Bhakuni
- Department of Anesthesiology, Govt. Medical College, Haldwani (Nainital), Uttarakhand, India
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Michailidou M, O’Keeffe T, Mosier JM, Friese RS, Joseph B, Rhee P, Sakles JC. A Comparison of Video Laryngoscopy to Direct Laryngoscopy for the Emergency Intubation of Trauma Patients. World J Surg 2014; 39:782-8. [DOI: 10.1007/s00268-014-2845-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Brück S, Trautner H, Wolff A, Hain J, Mols G, Pakos P, Roewer N, Lange M. Comparison of the C-MAC®and GlideScope®videolaryngoscopes in patients with cervical spine disorders and immobilisation. Anaesthesia 2014; 70:160-5. [DOI: 10.1111/anae.12858] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2014] [Indexed: 11/30/2022]
Affiliation(s)
- S. Brück
- Department of Anaesthesia and Critical Care; University Hospital of Würzburg; Würzburg Germany
- Department of Cardioanaesthesia; University Hospital of Ulm; Ulm Germany
| | - H. Trautner
- Department of Anaesthesia and Critical Care; University Hospital of Würzburg; Würzburg Germany
| | - A. Wolff
- Department of Anaesthesia and Critical Care; University Hospital of Würzburg; Würzburg Germany
| | - J. Hain
- Department of Mathematics; University of Würzburg; Würzburg Germany
| | - G. Mols
- Department of Anaesthesia and Critical Care; Ortenau Klinikum Lahr-Ettenheim; Lahr Germany
| | - P. Pakos
- Department of Neurosurgery; University Hospital of Würzburg; Würzburg Germany
| | - N. Roewer
- Department of Anaesthesia and Critical Care; University Hospital of Würzburg; Würzburg Germany
| | - M. Lange
- Department of Anaesthesia and Critical Care; University Hospital of Würzburg; Würzburg Germany
- Department of Anaesthesia and Critical Care; Mathias-Spital-Rheine; Rheine Germany
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Comparison of the Airtraq and the Macintosh laryngoscope for double-lumen tube intubation. Eur J Anaesthesiol 2013; 30:180-6. [DOI: 10.1097/eja.0b013e32835fe574] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Durga P, Kaur J, Ahmed SY, Kaniti G, Ramachandran G. Comparison of tracheal intubation using the Airtraq(®) and Mc Coy laryngoscope in the presence of rigid cervical collar simulating cervical immobilisation for traumatic cervical spine injury. Indian J Anaesth 2013; 56:529-34. [PMID: 23325936 PMCID: PMC3546238 DOI: 10.4103/0019-5049.104568] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND It is difficult to visualise the larynx using conventional laryngoscopy in the presence of cervical spine immobilisation. Airtraq(®) provides for easy and successful intubation in the neutral neck position. OBJECTIVE To evaluate the effectiveness of Airtraq in comparison with the Mc Coy laryngoscope, when performing tracheal intubation in patients with neck immobilisation using hard cervical collar and manual in-line axial cervical spine stabilisation. METHODS A randomised, cross-over, open-labelled study was undertaken in 60 ASA I and II patients aged between 20 and 50 years, belonging to either gender, scheduled to undergo elective surgical procedures. Following induction and adequate muscle relaxation, they were intubated using either of the techniques first, followed by the other. Intubation time and Intubation Difficulty Score (IDS) were noted using Mc Coy laryngoscope and Airtraq. The anaesthesiologist was asked to grade the ease of intubation on a Visual Analogue Scale (VAS) of 1-10. Chi-square test was used for comparison of categorical data between the groups and paired sample t-test for comparison of continuous data. IDS score and VAS were compared using Wilcoxon Signed ranked test. RESULTS The mean intubation time was 33.27 sec (13.25) for laryngoscopy and 28.95 sec (18.53) for Airtraq (P=0.32). The median IDS values were 4 (interquartile range (IQR) 1-6) and 0 (IQR 0-1) for laryngoscopy and Airtraq, respectively (P=0.007). The median Cormack Lehane glottic view grade was 3 (IQR 2-4) and 1 (IQR 1-1) for laryngoscopy and Airtraq, respectively (P=0.003). The ease of intubation on VAS was graded as 4 (IQR 3-5) for laryngoscopy and 2 (IQR 2-2) for Airtraq (P=0.033). There were two failures to intubate with the Airtraq. CONCLUSION Airtraq improves the ease of intubation significantly when compared to Mc Coy blade in patients immobilised with cervical collar and manual in-line stabilisation simulating cervical spine injury.
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Affiliation(s)
- Padmaja Durga
- Department of Anesthesiology, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad, Andhra Pradesh, India
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Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, Hagberg CA, Caplan RA, Benumof JL, Berry FA, Blitt CD, Bode RH, Cheney FW, Connis RT, Guidry OF, Nickinovich DG, Ovassapian A. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118:251-70. [PMID: 23364566 DOI: 10.1097/aln.0b013e31827773b2] [Citation(s) in RCA: 1142] [Impact Index Per Article: 103.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AbstractSupplemental Digital Content is available in the text.
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Affiliation(s)
- Jeffrey L Apfelbaum
- American Society of Anesthesiologists, 520 N. Northwest Highway, Park Ridge, IL 60068–2573, USA
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Healy DW, Maties O, Hovord D, Kheterpal S. A systematic review of the role of videolaryngoscopy in successful orotracheal intubation. BMC Anesthesiol 2012; 12:32. [PMID: 23241277 PMCID: PMC3562270 DOI: 10.1186/1471-2253-12-32] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 11/29/2012] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED 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.
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Affiliation(s)
- David W Healy
- Department of Anesthesiology, University of Michigan Hospital, 1500 East Medical Center Drive 1H247, Box 0048, Ann Arbor, Michigan 48109, USA
| | - Oana Maties
- Department of Anesthesiology, University of Michigan Hospital, 1500 East Medical Center Drive 1H247, Box 0048, Ann Arbor, Michigan 48109, USA
| | - David Hovord
- Department of Anesthesiology, University of Michigan Hospital, 1500 East Medical Center Drive 1H247, Box 0048, Ann Arbor, Michigan 48109, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan Hospital, 1500 East Medical Center Drive 1H247, Box 0048, Ann Arbor, Michigan 48109, USA
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Purugganan RV, Jackson TA, Heir JS, Wang H, Cata JP. Video Laryngoscopy Versus Direct Laryngoscopy for Double-Lumen Endotracheal Tube Intubation: A Retrospective Analysis. J Cardiothorac Vasc Anesth 2012; 26:845-8. [DOI: 10.1053/j.jvca.2012.01.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Indexed: 01/29/2023]
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White MC, Marsh CJ, Beringer RM, Nolan JA, Choi AYS, Medlock KE, Mason DG. A randomised, controlled trial comparing the Airtraq™ optical laryngoscope with conventional laryngoscopy in infants and children. Anaesthesia 2012; 67:226-31. [PMID: 22321076 DOI: 10.1111/j.1365-2044.2011.06978.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The Airtraq(™) optical laryngoscope became available in paediatric sizes in the UK in May 2008. We conducted a randomised, controlled trial comparing the Airtraq with conventional laryngoscopy during routine anaesthesia in children. We hypothesised that the Airtraq laryngoscope would perform as well as conventional laryngoscopy. Sixty patients (20 infants and 40 children) were recruited. The mean (SD) intubation time using the Airtraq was longer than conventional laryngoscopy overall (47.3 (32.6) vs 26.3 (11.5) s; p=0.002), though the difference was only significant for children (p=0.003) and not for infants (p=0.29). The Airtraq provided a better view of the larynx compared with conventional laryngoscopy (in infants (percentage of glottic opening scores 100 (95-100 [90-100]) vs 77 (50-90 [40-100]), respectively; p=0.001; visual analogue scores for field of view 9.2 (9.2-9.5 [8.2-10.0]) vs 6.8 (5.1-8.0 [4.7-10.0]), respectively; p=0.001). In children, the Airtraq provided a similar view of the larynx (percentage of glottic opening scores 100 (100-100 [40-100]) vs 100 (90-100 [50-100]), respectively; visual analogue scores for field of view 9.2 (8.6-10.0 [7.0-10.0]) vs 9.2 (8.6-10.0 [5.6-10.0]), respectively; both p>0.05), compared with conventional laryngoscopy.
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Affiliation(s)
- M C White
- Department of Anaesthetics, Bristol Royal Hospital for Children, Bristol, UK.
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Lu Y, Jiang H, Zhu YS. Airtraq laryngoscope versus conventional Macintosh laryngoscope: a systematic review and meta-analysis. Anaesthesia 2011; 66:1160-7. [DOI: 10.1111/j.1365-2044.2011.06871.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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