Endotracheal intubation in patients with difficult airway: using laryngeal mask airway with bougie versus video laryngoscopy

Video screen visualization patterns when using a video laryngoscope for tracheal intubation: A systematic review

OBJECTIVE

Published studies of video laryngoscopes are often limited by the lack of a clear definition of video laryngoscopy (VL). We performed a systematic review to determine how often published studies of VL report on video screen visualization.

METHODS

We searched PubMed, EMBASE and Scopus for interventional and observational studies in which a video laryngoscope equipped with a standard geometry blade was used for tracheal intubation. We excluded simulation based studies. Our primary outcome was data on video laryngoscope screen visualization. Secondary outcomes were explicit methodology for screen visualization.

RESULTS

We screened 4838 unique studies and included 207 (120 interventional and 87 observational). Only 21 studies (10% of 207) included any data on video screen visualization by the proceduralist, 19 in a yes/no fashion only (ie, screened viewed or not) and 2 with detail beyond whether the screen was viewed or not. In 11 more studies, visualization patterns could be inferred based on screen availability and in 16 more studies, the methods section stated how screen visualization was expected to be performed without reporting data collection on how the proceduralist interacted with the video screen. Risk of bias was high in the majority of included studies.

CONCLUSIONS

Published studies of VL, including many clinical trials, rarely include data on video screen visualization. Given the nuances of using a video laryngoscope, this is a critical deficiency, which largely prevents us from knowing the treatment effect of using a video laryngoscope in clinical practice. Future studies of VL must address this deficiency.

The teaching order of using direct laryngoscopy first may improve the learning outcome of endotracheal incubation: A preliminary, randomized controlled trial

BACKGROUND

Endotracheal intubation (ETI) is a life-saving procedure taught to medical students. We examined the influence of the order of teaching ETI through direct laryngoscopy (DL) and video laryngoscopy (VL) on learning by measuring the intubation time and learning curve of trainees, in order to explore ways to improve ETI performance.

METHODS

Twenty trainees were randomly divided into 2 groups. In the DL-first group, trainees used DL to perform ETI 10 times and then used VL 10 times, while the order was reversed in the VL-first group. Intubation time, number of intubation attempts, the Cormack-Lehane (CL) classification, and adverse events were recorded. The primary outcome was the cumulative summation (CUSUM). The CUSUM equation is defined as (Equation is included in full-text article.), where ct is the cumulative sum.

RESULTS

ETI was attempted on 400 patients. The difference in the mean times for the first 10 intubations between the 2 groups was not significant (P > .05). Mean intubation time for second series in the DL-first group was significantly shorter than that of the first series (P < .05), while there were no differences between the 2 series in the VL-first group (P > .05). The mean intubation time in the second series of the DL-first group was shorter than for the first series of the VL-first group (P < .05), while the mean intubation time of the first series by the DL-first group did not differ from the second series by the VL-first group (P > .05). Eighteen attempts were required to achieve an 80% intubation success rate for the DL-first group, while more than 20 attempts were required for the trainees in the VL-first group.

CONCLUSION

We consider that teaching trainees DL for tracheal intubation first.

CLINICAL TRIAL NUMBER

ChiCTR-OOR-16008364.

Massive ameloblastoma: A case report of difficult fiberoptic intubation

INTRODUCTION

Intubation can sometimes be difficult in patients with lesions in the mouth floor. Ameloblastoma is a frequently encountered tumor of the maxillofacial area. An extensive lesion might occupy the floor of the mouth, prevent displacement of the tongue, limiting the space for inserting a laryngoscope blade and resulting in difficult intubation even with fiberoptic bronchoscopy.

CASE PRESENTATION

A 66-year-old man (67 kg; 171 cm) with a mental swelling was diagnosed with ameloblastoma and scheduled for surgical resection. The tumor was extensive, occupying most of the anterior floor of the mouth. We were concerned about impossible direct laryngoscopy because the massive tumor in the floor of the mouth compressed the base of the tongue against the posterior wall of the pharynx, restricting the space for inserting the laryngoscope blade. Therefore, we planned to perform awake nasal fiberoptic intubation to secure the airway. Although the procedure was complicated by the massive tumor, successful intubation was achieved by hand-assisted alteration of the direction of the endotracheal tube (ETT) under direct laryngoscopy.

DISCUSSION

Awake fiberoptic intubation was complicated by the tumor protrusion to deviate the ETT. Discovering of the ETT deviation by the insufficient blade insertion facilitated visualizing the vocal cords with the fiberoptic scope.

CONCLUSION

Identification of ETT deviation even with insufficient blade insertion and hand-assisted alteration of the direction of the ETT might raise the chances of successful fiberoptic intubation. The anesthesiologist should be aware of the likelihood of failed fiberoptic intubation and plan for alternative approaches to secure the airway.

Comparing the efficacy and safety of laryngeal mask airway, streamlined liner of the pharyngeal airway and I-gel following tracheal extubation

Adverse events following surgical operations are common complications due to removal of tracheal tube in contrast to the tracheal intubation. Awareness about the new methods and strategies for tracheal tube extubation is necessary for a safe and successful extubation. Therefore, we aimed to assess the safety and efficacy of laryngeal mask airway (LMA), streamlined liner of the pharyngeal airway (SLIPA) and I-gel in extubation time of tracheal tube. A one-single randomized clinical trial was conducted in 105 eligible patients in three groups including LMA, SLIPA and I-gel. The patients were under surgery after general anesthesia with propofol (2-3 mg/kg) and fentanyl (1-2 μg/kg). Hemodynamic responses and extubation consequences including coughing rate, laryngospasm, airway obstruction, apnea, breath holding and straining of patients, vomiting, and need for re-intubation were recorded every 5 minutes since inserting of supraglottic airway devices (SADs) until patients restore consciousness. Analysis of data was conducted in SPSS software by analysis of variance (ANOVA) and ANOVA for repeated measurements tests. The overall successful insertion was 100% for LMA and I-Gel and this rate was 97.1% for SLIPA method. A significant decrease was observed in trend of hemodynamic responses in all three groups. Nevertheless, the MBP was lower in LMA group and lower HR was observed in I-Gel and higher HR occurred in SLIPA (P < 0.05). Three groups was same statistically regarding sore throat, vomiting, coughing, breath holding, apnea, laryngospasm, and re-intubation need (P > 0.05). However, the incidence rate of apnea, and laryngospasm, as well as re-intubation need in SLIPA group was 2.9%, respectively. LMA, I-GEL and SLIPA could be considered as useful and safe devices for ventilation control after tracheal tube removal at the end of operation. Three devices were same regarding to sore throat, vomiting, coughing, and breath holding. However, LMA showed lower side effects while SLIPA was related to more occurrences of apnea, laryngospasm, and re-intubation need.