The Comparison of Direct Laryngoscopy and Video Laryngoscopy in Pediatric Airways Management for Congenital Heart Surgery: A Randomized Clinical Trial

Airway Management of Critically Ill Pediatric Patients with Suspected or Proven Coronavirus Disease 2019 Infection: An Intensivist Point of View

Advanced airway management of critically ill children is crucial for novel coronavirus disease 2019 (COVID-19) management in the pediatric intensive care unit, whether due to shock and hemodynamic collapse or acute respiratory failure. In this article, intubation is challenging due to the particularities of children's physiology and the underlying disease's pathophysiology, especially when an airborne pathogen, like COVID-19, is present. Unfortunately, published recommendations and guidelines for COVID-19 in pediatrics do not address in-depth endotracheal intubation in acutely ill children. We discussed the caveats and pitfalls of intubation in critically ill children.

A Comparative Study of Video Laryngoscopy to Direct Laryngoscopy for Endotracheal Intubation in Pediatric Patients

Background

Direct laryngoscopy is the standard method for intubation in pediatric patients. The introduction of video laryngoscopy brought a paradigm shift in managing pediatric airways.

Objectives

We compared the tracheal intubation technique between direct and video laryngoscopy with McIntosh Blade 2 in pediatric patients 2 - 8 years of age requiring airway management. The glottic view and the first pass success rate were compared and analyzed.

Methods

An observational cross-sectional study was conducted with 120 children between 2 - 8 years with normal airways. They were divided into video laryngoscopy (Group V) and direct laryngoscopy (Group D). The primary outcome measures included time taken for intubation, number of attempts required, Cormack-Lehane glottic view, use of optimization maneuvers, the requirement of tube repositioning, and hemodynamic parameters before and after intubation.

Results

The time taken for intubation was longer in the video laryngoscopy group (group D, 24.28 sec vs. group V, 27.65 seconds (P = 0.01). The Cormack-Lehane glottic view was grade 1 in all the patients in the video laryngoscopy group, while only 35 children showed grade 1 in the direct laryngoscopy group. (P < 0.001). We observed a significant increase in both heart rate and mean arterial pressure in the video laryngoscopy group at 1, 3, 5, and 10 min after intubation (P < 0.001, P < 0.05).

Conclusions

The time taken for intubation was more in group V, but the glottic view was much better, and the requirement for external maneuvers was also less. Pressure response to intubation was more in group V compared to group D.

Transitioning from Direct to Video Laryngoscopy during the COVID-19 Pandemic Was Associated with a Higher Endotracheal Intubation Success Rate

OBJECTIVE

The objective of this study was to determine the effect of transitioning from direct laryngoscopy (DL) to video laryngoscopy (VL) on endotracheal intubation success overall and with enhanced precautions implemented during the COVID-19 pandemic.

METHODS

We examined electronic transport records from Mayo Clinic Ambulance Service, a large advanced life support (ALS) provider serving rural, suburban, and urban areas in Minnesota and Wisconsin, USA. We determined the success of intubation attempts when using DL (March 10, 2018 to December 19, 2019), VL (December 20, 2019 to September 29, 2021), and VL with an enhanced COVID-19 guideline that restricted intubation to one attempt, performed by the most experienced clinician, who wore enhanced personal protective equipment (April 1 to December 18, 2020). Success rates at first attempt and after any attempt were assessed for association with type of laryngoscopy (VL vs DL) after adjusting for patient age group, patient weight, use of enhanced COVID-19 guideline, medical vs trauma patient, and ALS vs critical care clinician. A secondary analysis further adjusted for degree of glottic visualization.

RESULTS

We identified 895 intubation attempts using DL and 893 intubation attempts using VL, which included 382 VL intubation attempts using the enhanced COVID-19 guideline. Success on first intubation attempt was 69.2% for encounters with DL, 82.9% overall with VL, and 83.2% with VL and enhanced COVID-19 protocols (DL vs overall VL: p < 0.001; COVID-19 vs non-COVID VL: p = 0.86). In multivariable analysis, use of VL was associate with higher odds of successful intubation on first attempt (odds ratio, 2.28; 95%CI, 1.73-3.01; p < 0.001) and on any attempt (odds ratio, 2.16; 95%CI, 1.58-2.96; p < 0.001) compared with DL. Inclusion of glottic visualization in the model resulted in a nonsignificant association between laryngoscopy type and successful first intubation (p = 0.41) and a significant association with the degree of glottic visualization (p < 0.001).

CONCLUSIONS

VL is designed to improve glottic visualization. The use of VL by a large, U.S. multistate ALS ambulance service was associated with increased odds of successful first-pass and overall attempted intubation, which was mediated by better visualization of the glottis. COVID-19 protocols were not associated with success rates.

Challenge of Lung Isolation in Patients with Vocal Cord Implants

Glottic closure insufficiency increases the risk of aspiration and pneumonia, particularly in the elderly. Medialization thyroplasty is an open surgical procedure for treating glottic incompetency by approximating both vocal folds. The vocal fold medialization is achieved by inserting an implant to bring the nonmobile fold to the unaffected side. Lung isolation in patients with vocal cord implantation poses a unique challenge. Understanding the risks of different modalities of lung isolation and their impacts on the vocal cord implant is crucial to implementing a specifically tailored plan. Preoperative bronchoscopy, intraoperative video laryngoscopy, and bronchoscopy are ideal methods for assessing the vocal fold implants and guiding the lung isolation technique. Bronchial blocker through a single-lumen endotracheal tube may be the preferred choice to avoid the injury of the stretched vocal cords and dislodgement of the implant by a larger diameter double-lumen tube.

Diagnostic Accuracy of Suprasternal Versus Subxiphoid Ultrasonography for Endotracheal Intubation

Background

Airway management is an important skill for emergency physicians, and confirmation of correct endotracheal tube (ETT) placement is a crucial component of airway management.

Objectives

Due to the occurrence of incorrect ETT positioning in emergency departments, the present study aimed to compare the diagnostic sensitivity of ultrasound using suprasternal and subxiphoid methods for confirming the correct placement of ETT compared to capnography.

Methods

This cross-sectional study was conducted by examining patients requiring intubation. Ultrasound was performed by two independent emergency medical assistants using two suprasternal and subxiphoid methods to confirm correct ETT placement; the results were then interpreted. To observe the tube passage through the vocal cords, capnography and lung auscultation were applied as the gold standards, and the results of two ultrasound methods were compared.

Results

A total of 66 patients, who were intubated in the emergency department, participated in this study. The positive and negative predictive values, sensitivity, and specificity of supernatural ultrasound were 96.72%, 80%, 98.33%, and 66.67%, respectively. Also, positive and negative predictive values, sensitivity, and specificity of subxiphoid ultrasound were 97.95%, 29.41%, 80%, and 83.33%, respectively. The diagnostic odds ratios of suprasternal and subxiphoid ultrasounds were 1.026 and 1.024 compared to capnography, respectively.

Conclusions

Ultrasonography using the suprasternal method was feasible. Considering the high sensitivity and specificity of this method in confirming correct ETT placement, it produced reliable results. Overall, this modality can be used as one of the main methods to verify correct ETT placement in emergency departments.

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.

Diagnostic Accuracy of Combined Mallampati and Wilson Score to Predict Difficult Intubation in Obese Patients: A Descriptive Cross-Sectional Study

Background

Airway protection during anesthesia is often the primary concern of anesthetists when working with obese patients and always is a difficult task due to increased exposure to harmful effects of apnea, hypoxia, and impaired respiratory mechanics.

Objectives

The primary goal of this research was to determine the diagnostic accuracy of combined Mallampati and Wilson score in detecting difficult intubation in obese patients undergoing surgery by taking the Cormack-Lehane grading on direct laryngoscopy and intubation as the gold standard.

Methods

This descriptive cross-sectional study was done in 300 obese patients with BMI > 29.9 kg/m². Modified Mallampati and Wilson score was recorded preoperatively for each patient in the sitting position by the primary investigator. Endotracheal intubation grades were also recorded, and grades IIb, III, and IV were regarded as difficult intubation according to the Cormack-Lehane intubation classification.

Results

The mean age was 46.76 ± 15.57 years. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of the combined Mallampati and Wilson score for detecting difficult laryngoscopy and difficult intubation were 75.0, 98.8, 92.9, 95.0, and 94.6%, respectively.

Conclusions

Combined Mallampatti and Wilson score is highly accurate in the initial diagnostic workup of obese patients at risk of difficult intubation. It is easy to calculate and lower the risk of intubation-related complications and failure.

Comparative Evaluation of Difficult Intubation Predictors in Children Under Two Years of Ages

Background

Tracheal intubation is the most reliable way of securing an airway. Pediatric airway management is one of the significant challenges, especially for non-pediatric anesthesiologists. Early airway evaluation for detecting difficult intubation and preventing catastrophic events is necessary before anesthesia, especially in children.

Objectives

Therefore, this study was done to compare some valuable adult predictors in children under two years of age.

Methods

This prospective descriptive-analytical study was performed on 405 children under two years of age that were referred for elective surgery under general anesthesia with endotracheal intubation in Imam Hossein Hospital, Isfahan. Under sedation in a supine position, we measured items, including age, weight, height, stern omental distance (SMD), mouth opening (MO), neck circumference (NC), acromio-axillo-suprasternal notch index (AASI), and intubation difficulty scale score (IDS). An expert anesthesiologist did laryngoscopy and intubation, and difficult cases were recorded.

Results

Our study showed that the frequency of difficult intubation with IDS > 4 was %16, and with IDS > 5 was %3. The variables, including age, weight, height, and SMD, significantly predicted difficult intubation. The cut-off points for age < 6 months, weight < 5/9 kg, height < 61 cm, and SMD < 5/3 cm were obtained, respectively. Other variables, such as MO, AASI, NC, and sex, were unreliable predictors for difficult intubation.

Conclusions

We found that IDS > 4, age< 6-month, weight < 5/9 kg, and SMD < 5/3 cm are predictors for difficult intubation. It is helpful for the anesthesiologist to measure these predictions before anesthesia is started to find who has difficult intubation.

Comparison of RAMP and New Modified RAMP Positioning in Laryngoscopic View During Intubation in Patients with Morbid Obesity: A Randomized Clinical Trial

Background

The prevalence of obesity is increasing worldwide, and anesthesiologists are facing challenges in the airway management of such patients. Excessive adipose tissue influences pharyngeal spaces and affects the laryngoscopic grade. Standard ramp positioning is time-consuming and difficult to prepare, and requires expensive equipment.

Objectives

The aim of this study was to compare the standard ramp position with the proposed low-cost and easily accessible modified ramp position in laryngoscopic view during the intubation of patients with morbid obesity.

Methods

In this single-blind clinical trial, 84 patients candidate for bariatric surgery at Rasoul Akram Hospital in 2020 were assigned to the rapid airway management positioner (RAMP) (R) and new modified RAMP (MR) groups by the block randomization method. The laryngoscopic view of the glottis based on the Cormack-Lehane scale, ventilation quality, duration of intubation, intubation attempts, oxygen saturation at the end of intubation, and the need for backward, upward, rightward pressure (BURP) maneuver for successful intubation were recorded. Normal distribution tests and Mann-Whitney and Kruskal-Wallis tests were used to analyze the data.

Results

The results showed no significant differences between the two groups regarding ventilation score, laryngoscopy grade, number of intubation attempts, duration of intubation, and the need for BURP maneuvers during intubation (P > 0.05).

Conclusions

The two methods are not significantly different, and the new modified ramp position can be used with more ease and availability and less cost.

Intubating Through Supraglottic Airway Devices: A Narrative Review

Implication Statement: Despite the increasing popularity of video laryngoscopes, the supraglottic airway device (SAD) remains a critical airway rescue tool. The SAD provides a conduit for tracheal intubation in failed laryngoscopy. This article aims to help the operator: (1) select an intubating SAD with consistent performance; (2) inform the appropriate SAD-endotracheal tube pairings; and (3) explain various SAD and endotracheal tube maneuvers available to increase chances of successful intubation. Objectives: The first supraglottic airway device (SAD) was introduced more than thirty years ago. Since then, SADs have undergone multiple iterations and improvements. The SAD remains an airway rescue device for ventilation and an intubation conduit on difficult airway algorithms. Data Sources: Several SADs are specifically designed to facilitate tracheal intubation, i.e., “intubating SADs,” while most are “non-intubating SADs.” The two most commonly reported tracheal intubation methods via the SADs are the blind and visualized passage of the endotracheal tube (ETT) preloaded on a fiberoptic scope. Fiberoptic guided tracheal intubation (FOI) via an intubating SAD generally has higher success rates than blind intubations and is thus preferred. However, fiberscopes might not always be readily available, and anesthesiologists should be skilled to successfully intubate blindly through a SAD. Summery: This narrative review describes intubating SAD with consistent performance, appropriate SAD-ETT pairings, and various SAD and ETT maneuvers to increase successful intubation chances.

Invasive Airway "Intubation" in COVID-19 Patients; Statistics, Causes, and Recommendations: A Review Article

CONTEXT

Severe coronavirus disease 2019 (COVID-19) can induce acute respiratory distress, which is characterized by tachypnea, hypoxia, and dyspnea. Intubation and mechanical ventilation are strategic treatments for COVID-19 distress or hypoxia.

METHODS

We searched PubMed, Embase, and Scopus databases to identify relevant randomized control trials, observational studies, and case series published from April 1, 2021.

RESULTS

24 studies were included in this review. Studies had been conducted in the USA, China, Spain, South Korea, Italy, Iran, and Brazil. Most patients had been intubated in the intensive care unit. Rapid sequence induction had been mostly used for intubation. ROX index can be utilized as the predictor of the necessity of intubation in COVID-19 patients. According to the studies, the rate of intubation was 5 to 88%. It was revealed that 1.4 - 44.5% of patients might be extubated. Yet obesity and age (elderly) are the only risk factors of delayed or difficult extubation.

CONCLUSIONS

Acute respiratory distress in COVID-19 patients could require endotracheal intubation and mechanical ventilation. Severe respiratory distress, loss of consciousness, and hypoxia had been the most important reasons for intubation. Also, increased levels of C-reactive protein (CRP), ferritin, d-dimer, and lipase in combination with hypoxia are correlated with intubation. Old age, diabetes mellitus, respiratory rate, increased level of CRP, bicarbonate level, and oxygen saturation are the most valuable predictors of the need for mechanical ventilation. ICU admission mortality following intubation was found to be 15 to 36%. Awake-prone positioning in comparison with high-flow nasal oxygen therapy did not reduce the risk of intubation and mechanical ventilation. There was no association between intubation timing and mortality of the infected patients. Noninvasive ventilation may have survival benefits.