Combined use of a McGrath® MAC video laryngoscope and Frova Intubating Introducer in a patient with Pierre Robin syndrome: a case report

Difficult intubation in syndromic versus nonsyndromic forms of micrognathia in children

BACKGROUND

We investigated how syndromic versus nonsyndromic forms of micrognathia impacted difficult intubation outcomes in children. Primary outcome was the first-attempt success rate of tracheal intubation, secondary outcomes were number of intubation attempts and complications. We hypothesized that syndromic micrognathia would be associated with lower first-attempt success rate.

METHODS

In micrognathic patients enrolled in the Pediatric Difficult Intubation Registry (08/2012-03/2019) we retrospectively compared demographic and clinical characteristics between children with nonsyndromic and syndromic micrognathia using standardized mean differences (SMD) and assessed the association of the presence of syndrome with the primary and secondary outcomes using propensity score matching analysis with and without matching for airway assessment findings.

RESULTS

Nonsyndromic patients (628) were less likely to have additional airway abnormalities. Syndromic patients (216) were less likely to have unanticipated difficult intubation (2% vs. 20%, SMD 0.59). First-attempt success rates of intubation were: 38% in the syndromic versus 34% in the nonsyndromic group (odds ratio [OR] 1.18; 95% confidence intervals [95% CI] 0.74, 1.89; p = .478), and 37% versus 37% (OR 0.99; 95% CI 0.66, 1.48; p = .959). Median number of intubation attempts were 2 (interquartile range [IQR]: 1, 3; range: 1, 8) versus 2 (IQR: 1, 3; range 1, 12) (median regression coefficient = 0; 95% CI: -0.7, 0.7; p = .999) and 2 (IQR: 1, 3; range: 1, 12) versus 2 (IQR: 1, 3; range 1, 8) (median regression coefficient = 0; 95% CI: -0.5, 0.5; p = .999). Complication rates were 14% versus 22% (OR 0.6; 95% CI 0.34, 1.04; p = .07) and 16% versus 21% (OR 0.71; 95% CI 0.43, 1.17; p = .185).

CONCLUSIONS

Presence of syndrome was not associated with lower first-attempt success rate on intubation, number of intubation attempts, or complication rate among micrognathic patients difficult to intubate, despite more associated craniofacial abnormalities. Nonsyndromic patients were more likely to have unanticipated difficult intubations, first attempt with direct laryngoscopy.

2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway

The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care; Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.

Which Device Is Favorable for Intubation Attempts of Pediatric Residents on Four Different Pediatric Airway Simulations?

OBJECTIVES

Endotracheal intubation is an essential skill for the pediatric airway management. Although direct laryngoscopy (DL) is the standard method, several videolaryngoscopes (VLs) have been recently enhanced as an alternative especially for difficult intubations. We aimed to compare McGrath MAC (McG) and Storz C-MAC PM (ST) VLs with DL in terms of intubation success rate, time to intubation (TTI), and duration of obtaining glottis view of intubation attempts performed by pediatric residents on different pediatric airway manikins.

METHODS

The pediatric residents with no experience in videolaryngoscopy were included. After a brief demonstration, intubation attempts with 3 randomly handled different devices with 6 different blades were performed on a child manikin, an infant manikin, a Pierre-Robin sequence infant manikin, and a child manikin with cervical immobilization sequentially.

RESULTS

Fifty pediatric residents were enrolled. The attempts of DL on child manikin and attempts of all devices on child with cervical immobilization simulation were completely successful. For the attempts on both infant manikin and Pierre-Robin sequence infant manikin, the success rate of McG was significantly lower than ST and DL (P = 0.011 and P = 0.001). In the child manikin, McG and ST had prolonged TTI compared with DL (P = 0.016 and P = 0.001). For the child with cervical immobilization simulation, TTI of DL was significantly shorter than McG and ST (P = 0.011 and P = 0.001). Time to intubation of McG was significantly longer than DL and ST for the attempts on both 2 infant manikins. The rate of Cormack-Lehane grade I glottis view was similar for the attempts on both 2 child airway simulations. For infant manikin and Pierre-Robin sequence infant simulation, the rate of Cormack-Lehane grade I of ST was higher than attempts of DL and McG.

CONCLUSIONS

The attempts of pediatric residents on infant normal airway and Pierre-Robin sequence infant airway simulations resulted with enhanced glottis view by the utilization of Storz C-MAC PM, but both 2 VLs did not provide the improvement of intubation success rate and TTI compared with DL on these 4 different pediatric manikins. Further clinical studies of different VLs in different clinical courses are required for a reliable utilization in children.

Comparison of Glidescope Core, C-MAC Miller and conventional Miller laryngoscope for difficult airway management by anesthetists with limited and extensive experience in a simulated Pierre Robin sequence: A randomized crossover manikin study

BACKGROUND

Video laryngoscopy is an effective tool in the management of difficult pediatric airway. However, evidence to guide the choice of the most appropriate video laryngoscope (VL) for airway management in pediatric patients with Pierre Robin syndrome (PRS) is insufficient. Therefore, the aim of this study was to compare the efficacy of the Glidescope® Core™ with a hyperangulated blade, the C-MAC® with a nonangulated Miller blade (C-MAC® Miller) and a conventional Miller laryngoscope when used by anesthetists with limited and extensive experience in simulated Pierre Robin sequence.

METHODS

Forty-three anesthetists with limited experience and forty-three anesthetists with extensive experience participated in our randomized crossover manikin trial. Each performed endotracheal intubation with the Glidescope® Core™ with a hyperangulated blade, the C-MAC® with a Miller blade and the conventional Miller laryngoscope. "Time to intubate" was the primary endpoint. Secondary endpoints were "time to vocal cords", "time to ventilate", overall success rate, number of intubation attempts and optimization maneuvers, Cormack-Lehane score, severity of dental trauma and subjective impressions.

RESULTS

Both hyperangulated and nonangulated VLs provided superior intubation conditions. The Glidescope® Core™ enabled the best glottic view, caused the least dental trauma and significantly decreased the "time to vocal cords". However, the failure rate of intubation was 14% with the Glidescope® Core™, 4.7% with the Miller laryngoscope and only 2.3% with the C-MAC® Miller when used by anesthetists with extensive previous experience. In addition, the "time to intubate", the "time to ventilate" and the number of optimization maneuvers were significantly increased using the Glidescope® Core™. In the hands of anesthetists with limited previous experience, the failure rate was 11.6% with the Glidescope® Core™ and 7% with the Miller laryngoscope. Using the C-MAC® Miller, the overall success rate increased to 100%. No differences in the "time to intubate" or "time to ventilate" were observed.

CONCLUSIONS

The nonangulated C-MAC® Miller facilitated correct placement of the endotracheal tube and showed the highest overall success rate. Our results therefore suggest that the C-MAC® Miller could be beneficial and may contribute to increased safety in the airway management of infants with PRS when used by anesthetists with limited and extensive experience.

Combined use of a videolaryngoscope and a flexible bronchoscope for awake tracheal intubation when front-of-neck airway is not an option

We report a case of successful tracheal intubation with the combined use of a videolaryngoscope and flexible bronchoscope in a patient with difficult airway when both techniques had individually failed. A 35-year-old man presented with airway obstruction due to massive neck swelling causing hypoxia, stridor and respiratory distress. He had a history of oral cancer which had been resected with bilateral neck dissection and free flap reconstruction 2 months previously. Due to extensive anterior neck swelling, we judged that front-of-neck airway would not be a suitable approach. After unsuccessful attempts at awake tracheal intubation with videolaryngoscopy and flexible bronchoscopy separately, we combined both techniques with a successful outcome. By using a combined technique to address the specific problems presented by this case, a life-threatening emergency was resolved. This case highlights why it is useful for anaesthetists to be familiar with multiple techniques to awake tracheal intubation, both individually and in combination.

Comparison of conventional C-MAC video laryngoscope guided intubation by anesthesia trainees with and without Frova endotracheal introducer: A randomized clinical trial

BACKGROUND AND AIMS

Successful intubation with video laryngoscopes necessitates good hand-eye coordination and the use of intubation adjuncts like bougie and stylet. We proposed this study to find whether using Frova introducer with C-MAC video laryngoscope will reduce the intubation time in trainee anesthesiologists.

MATERIAL AND METHODS

We enrolled 140 adults without any difficult airway predictors. They were randomly assigned to undergo C-MAC video laryngoscope guided intubation by anesthesia residents using tracheal tube preloaded over Frova introducer (n = 70) or without Frova introducer (n = 70). Primary outcome was the intubation time. Secondary outcomes were the number of redirections of tracheal tube or Frova introducer toward glottis, need for external laryngeal maneuvers (ELMs), first attempt intubation success rate, and ease of intubation.

RESULTS

The median actual intubation time (IQR) in Frova and non-Frova group, respectively, were 25.46 (28.11-19.80) and 19.96 (26.59-15.52) s (P = 0.001). The number of redirections of TT or Frova introducer toward glottis, first attempt success rate, and ease of intubation were comparable. The need for ELMs [n (%)] was 15 (21.4) and 26 (37.1) in Frova and non-Frova group, respectively (P = 0.04).

CONCLUSION

Frova introducer guided endotracheal intubation with C-MAC videolaryngoscope in patients with normal airways had a marginally prolonged intubation time with a significant reduction in the need of external laryngeal manoeuvres but with a comparable number of redirections and attempts. Further research is needed to generalize these findings to patients with difficult airways.

Videolaryngoscopy Bails us out of Difficult Intubation Scenarios in Syndromic Children: A Case Series

Airway management in children with craniofacial anomalies can be complicated and may require multiple attempts with conventional direct laryngoscopy (DL). Videolaryngoscopes (VLs) have a well-established role in difficult airway management in adults; however, their role remains to be fully elucidated in paediatric age group. There is a relative paucity in the literature regarding the role of VLs in cases of syndromic children, and it is not clear whether they should be used as an initial option or as a rescue device. Herein, we report a series of cases of children with Pierre Robin sequence, Beckwith–Wiedemann syndrome, and Hurler’s syndrome wherein VLs proved beneficial after multiple failed DL attempts. Following initial failed attempts to intubate using DL, these children were subsequently intubated using VLs. Therefore, VLs should be used for initial intubation attempts in syndromic children with potential difficult airways.

Successful airway management with combined use of McGrath® MAC video laryngoscope and fiberoptic bronchoscope in a severe obese patient with huge goiter -a case report

Huge goitor can lead to tracheal compression and hence difficulty in intubation. This is compounded by severe obesity. Failed tracheal intubation in difficult intubation is a serious event that may lead to increased patient morbidity and mortality. Current intubation rescue techniques and combination of different rescue techniques may increase the success rate of difficult intubation. In a 47-year-old female patient, with severe obesity and a huge goiter, our attempts at intubation using direct laryngoscope, video laryngoscope, and awake fiberoptic bronchoscope had failed. We succeeded by applying video laryngoscope to improve visualization of the airway and fiberoptic bronchoscope as a stylet for endotracheal tube.

A before-and-after observational study of a protocol for use of the C-MAC videolaryngoscope with a Frova introducer in pre-hospital rapid sequence intubation

Results using videolaryngoscopy in pre-hospital rapid sequence intubation are mixed. A bougie is not commonly used with videolaryngoscopy. We hypothesised that using videolaryngoscopy and a bougie as core elements of a standardised protocol that includes a drugs and a laryngoscopy algorithm would result in a high first-pass tracheal intubation success rate. We employed videolaryngoscopy (C-MAC) combined with a bougie (Frova intubating introducer) in an anaesthetist-staffed helicopter emergency medical service. Data for adult tracheal intubation were collected prospectively as part of the airway registry of our unit for 22 months after implementation of the protocol (n = 543) and compared with controls (n = 238) treated in the previous year before the implementation. The mean first-pass success rate (95%CI) was 98.2% (96.6-99.0%) in the study group and 85.7% (80.7-89.6%) in the control group, p < 0.0001. Combining C-MAC videolaryngoscopy and bougie with a standardised rapid sequence induction protocol leads to a high first attempt intubation success rate when performed by an anaesthetist-led helicopter emergency medical service team.

Effect of Cricoid Pressure on Laryngeal View During Macintosh, McGrath MAC X-Blade and GlideScope Video Laryngoscopies

Objective

Cricoid pressure is useful in fasted patients requiring emergency intubation. We compared the effect of cricoid pressure on laryngeal view during Macintosh, McGrath MAC X-Blade and GlideScope video laryngoscopy.

Methods

After obtaining approval from the Human Research Ethics Committee and written informed consent from patients, we enrolled 120 patients (American Society of Anesthesiologists I-II, age 18-65 years) undergoing elective surgery that required endotracheal intubation in this prospective randomised study. Patients were divided into three groups (Macintosh, McGrath MAC X-Blade and GlideScope).

Results

Demographic and airway variables were similar in the groups. Cormack-Lehane grades were improved or unchanged on using cricoid pressure in Macintosh and McGrath MAC X-Blade groups. However, laryngeal views worsened in 12 patients (30%), remained unchanged in 26 patients (65%) and improved in 2 patients (5%) in the GlideScope group (p<0.001). Insertion and intubation times for Macintosh and McGrath MAC X-Blade video laryngoscopes were similar. Insertion times for GlideScope and Macintosh video laryngoscopes were similar, but were longer than those for the McGrath MAC X-Blade video laryngoscope (p=0.02). Tracheal intubation took longer with the GlideScope video laryngoscope than with the other devices (p<0.001 and p=0.003). Mean arterial pressures after insertion increased significantly in Macintosh and GlideScope groups (p=0.004 and p=0.001, respectively) compared with post-induction values. Heart rates increased after insertion in all three groups compared with post-induction values (p<0.001). Need for optimisation manoeuvres and postoperative minor complications were comparable in all three groups.

Conclusion

Although all three devices are useful for normal or difficult intubation, cricoid pressure improved Cormack-Lehane grades of Macintosh and McGrath MAC X-Blade video laryngoscopes but statistically significantly worsened that of the GlideScope video laryngoscope.