Complications and degree of difficulty of orotracheal intubation in the Intensive Care Unit before and after the establishment of an intubation protocol for critically ill patients: a prospective, observational study

OBJECTIVE

The objective of our study was to compare the degree of difficulty and complications related to tracheal intubation in an Intensive Care Unit (ICU) before and after the introduction of an intubation protocol based on the Difficult Airway Society guidelines for the management of tracheal intubation in critically ill adults, published in 2018.

METHODS

Prospective, observational study comparing all intubations performed in our ICU over 2 periods: pre-protocol (January 2015-January 2019) and post-protocol (February 2019-July 2022). The material used for intubation, the degree of difficulty, and intubation-related complications were recorded.

RESULTS

During the study period, 661 patients were intubated - 437 in the pre-protocol period (96% by direct laryngoscopy) and 224 in the post-protocol period (53% with direct laryngoscopy, 46% with video laryngoscopy). We observed an improvement in laryngeal view in the post-protocol period compared to the pre-protocol period (Cormack-Lehane ≥ 2b in 7.6% vs. 29.8%, p < 0.001), and a decrease in the number of moderate-to-severely difficult intubations (6.7% vs. 17.4%, p < 0.001). The first-pass success rate was 92.8% in the post-protocol period compared to 90.2% pre-protocol (p = 0.508). We did not find significant differences in complications between the periods studied.

CONCLUSIONS

Intubations performed in the post-protocol period were associated with improved laryngeal view and fewer cases of difficult intubation compared with the pre-protocol period.

Feasibility study of intubation in lateral position using Viva-sight double-lumen tube combined with video laryngoscope in patients undergoing pulmonary lobectomy

BACKGROUND

Double-lumen tube (DLT) intubation in lateral decubitus position is rarely reported. We designed this study to evaluate the feasibility of VivaSight double-lumen tube (VDLT) intubation assisted by video laryngoscope in lateral decubitus patients.

METHODS

Patients undergoing elective video-assisted thoracoscopic surgery (VATS) for lung lobectomy were assessed for eligibility between January 2022 and December, 2022. Eligible patients were randomly allocated into supine intubation group (group S) and lateral intubation group (group L) by a computer-generated table of random numbers. The prime objective was to observe whether the success rate of VDLT intubation in lateral position with the aid of video laryngoscope was not inferior to that in supine position.

RESULTS

A total of 116 patients were assessed, and 88 eligible patients were randomly divided into group L (n = 44) and group S (n = 44). The success rate of the first attempt intubation in the L group was 90.5%, lower than that of S group (97.7%), but there was no statistical difference (p > 0.05). Patients in both groups were intubated with VDLT for no more than 2 attempts. The mean intubation time was 91.98 ± 26.70 s in L group, and 81.39 ± 34.35 s in S group (p > 0.05). The incidence of the capsular malposition in the group L was 4.8%, less than 36.4% of group S (p < 0.001). After 24 h of follow-up, it showed a higher incidence of sore throat in group S, compared to that in group L (p = 0.009).

CONCLUSION

Our study shows the comprehensive success rate of intubation in lateral decubitus position with VDLT assisted by video laryngoscope is not inferior to that in supine position, with less risk of intraoperative tube malposition and postoperative sore throat.

TRIAL REGISTRATION

Chinese Clinical Trail Register (ChiCTR2200062989).

A Case of Anterior Arytenoid Cartilage Dislocation During Nasal Tracheal Intubation Using an Indirect Video Laryngoscope

Arytenoid cartilage dislocation can occur as a complication of tracheal intubation and laryngeal trauma, but its occurrence with indirect video laryngoscopy has not been reported. This paper reports anterior arytenoid dislocation occurring after nasotracheal intubation performed under indirect laryngoscopy using a video laryngoscope (McGRATH MAC; Medtronic). The dislocation is presumed to have resulted from the laryngoscope blade being initially inserted too deeply and applying pressure to the posterior aspect of the left cricoarytenoid joint. This patient's anterior arytenoid dislocation was treated conservatively using speech therapy with resolution occurring approximately 40 days postoperatively. On the 74th day after surgery, fibroscopic examination confirmed recovery and healing of the dislocation. However, other types of arytenoid dislocations and laryngeal injuries may require alternative treatment. Early consultation with an otolaryngologist is recommended if arytenoid dislocation is suspected.

Video laryngoscopy and direct laryngoscopy for cardiac arrest: A meta-analysis of clinical studies and trials

BACKGROUND

Intubation is an essential procedure in cardiopulmonary resuscitation (CPR). We conducted a systematic review and meta-analysis of trials and studies comparing the performance of video laryngoscope (VL) and direct laryngoscope (DL) in endotracheal intubation (ETI) during CPR in cardiac arrest (OHCA) patients.

METHODS

We searched the PUBMED, EMBASE, and Cochrane library databases. We analyzed the first-pass success rate, total intubation time, Cormack-Lehane grade (CL grade), esophageal intubation rate, and dental injury rate among the in-hospital cardiac arrest (IHCA) patients or out-of-hospital cardiac arrest (OHCA) patients. We demonstrated the pooled results of continuous outcomes by mean difference (MD) and dichotomous outcomes by odds ratio (OR), with a 95% confidence interval (CI) using a random-effects model.

RESULTS

We obtained six observational studies and one randomized control trial. The pooled results showed a significant increase in first-pass success rate (OR: 1.86, 95% CI: 1.41, 2.47), Cormack-Lehane (CL) grade (OR: 2.01, 95% CI: 1.59,2.53), and a decrease of esophageal intubation rate (OR: 0.25, 95% CI: 0.08, 0.85) in the VL group compared with DL group. Also, a non-significant decrease in dental injury rate [OR: 0.23, 95% CI: 0.05, 1.08) was observed in the VL group compared with the DL group. There was no statistical difference between the VL and DL groups, although the VL group seemed to have a shorter total intubation time (MD: -15.43, 95% CI: -34.67, 3.81). Types of laryngoscopes were not associated with the rate of ROSC [OR 1.01 (0.95,1.07); P = 0.83]. No differences in survival outcomes were observed between the two approaches.

CONCLUSIONS

Compared to DL, VL was found to be associated with first-pass success and CL grade. We recommend prioritizing VL over DL when performing ETIs for patients with cardiac arrest.

3D VOSNet: Segmentation of endoscopic images of the larynx with subsequent generation of indicators

Video laryngoscope is available for visualizing the motion of vocal cords and aid in the assessment of analyzing the larynx-related lesion preliminarily. Laryngeal Electromyography (EMG) needs to be performed to diagnose the factors of vocal cord paralysis, which may cause patient feeling unwell. Thus, the problem is the lack of credible larynx indicators to evaluate larynx-related diseases in the department of otolaryngology. Therefore, this paper aims to propose a 3D VOSNet model, which has the characteristics of sequence segmentation to extract the time-series features in the video laryngoscope. The 3D VOSNet model can keep the time-series features of three images before and after of the specific image to achieve translation and occlusion invariance, which explicitly signifies that our model can segment and classify each item in the video of laryngoscopy not affected by extrinsic causes such as shaking or occlusion during laryngoscope. Numerical results revealed that the testing accuracy rates of the glottal, right vocal cord, and the left vocal cord are 89.91%, 94.63%, and 93.48%, respectively. Our proposed model can segment glottal and vocal cords from the sequence of laryngoscopy. Finally, using the proposed algorithm computes six larynx indicators, which are the area of the glottal, area of vocal cords, length of vocal cords, deviation of length of vocal cords, and symmetry of the vocal cords. In order to assist otolaryngologists in staying credible and objective when making decisions without any doubt during diagnosis and also explaining the clinical symptoms of the larynx such as vocal cord paralysis to patients after diagnosis, our proposed algorithm provides otolaryngologists with explainable indicators (X-indicators).

Anesthetic induction and endotracheal intubation in the sitting position due to the fixed forearm caught by a meat grinder

A male patient was scheduled for urgent amputation of his right forearm. His right forearm was stuck inside the insertion slot of a meat grinder, resulting in severe pain to his injured arm. His upper body could not move to sit in a semi-upright position. An endotracheal tube was successfully placed after rapid sequence intubation using a video laryngoscope from behind the patient on the first attempt. This case report is the first documentation of successful anesthetic induction with subsequent endotracheal intubation using a video laryngoscope from behind an injured patient whose upper body was upright with limited positioning.

A comparative study of Video laryngoscope vs Macintosh laryngoscope for prehospital tracheal intubation in Hiroshima, Japan

Background

In Japan, there are no studies comparing endotracheal intubation performed by emergency medical technicians (EMTs) during out-of-hospital cardiac arrest (OHCA) using a Macintosh laryngoscope and a video laryngoscope.

Objective

The purpose of this study was to compare the success rate, complication rate, return of spontaneous circulation (ROSC), neurological prognosis (CPC1-2) and regional differences between Video laryngoscope (VL) and Macintosh laryngoscope (ML) for OHCA patients.

Method

This study is a retrospective cohort study using 10,067 OHCA data extracted from the national Utstein Form and emergency medical transport data. The primary endpoint was the success rate of tracheal intubation and the complication rate and the secondary endpoints were the incidence of ROSC and CPC1-2.

Results

A total of 885 tracheal Intubated OHCA patients were enrolled in this study. The success rate was 94.1% (490/521) in the VL group and 89.3% (325/364) in the ML group (RR, 1.05; 95%CI, 1.01-1.10, P = 0.01), the VL group shows significantly higher success rate than that of the ML group. In the complication rates, oesophageal intubation occurred in 0.2% (1/521) of in the VL group and in 6.0% (22/364) in the ML group, Indicating significantly higher complication rates in the ML group compared with the VL group (RR, 1.06; 95% CI, 1.03-1.09, P < 0.001). The ROSC rate and CPC1-2 rate are similar among the groups.

Conclusion

Our data suggest that using VL had a little advantage with a higher success rate and lower complication rate. Further discussion is necessary for the future development of Emergency Medical Services (EMS) intubation devices.

An optimal tracheal tube preshaping strategy for endotracheal intubation using video laryngoscopy: a randomized controlled trial

Although video laryngoscopy solves the problem of glottis exposure, it is difficult to deliver the tube to the glottic opening when the tracheal tube is unevenly shaped. This study aimed to compare the effects of different tube shapes on the first-pass success (FPS) rate in patients undergoing video laryngoscopy-assisted tracheal intubation. Three hundred patients above 18 years of age who underwent general anaesthesia and required endotracheal intubation were included in the study. The participants were randomly allocated to three groups with 100 participants in each group as follows: Group A, video laryngoscopes with a self-equipped stylet are used for tube preshaping; Group B: curvature of the video laryngoscope blade is modelled for tube preshaping; Group C: tube preshaping angle is consistent with the video laryngoscope blade, and the bending point is set 1 cm above the tracheal tube cuff. The primary outcome was FPS rates. The secondary outcomes included time to tracheal intubation, haemodynamic responses and adverse events. No significant differences in patient characteristics or airway assessments were noted (P > 0.05). Compared with Groups A, Group B and Group C exhibited a higher FPS rate (68% vs. 86% vs. 92%; P < 0.001). However, there is no significant difference in FPS rate between Group B and Group C (P > 0.05). And the time to tracheal intubation in Group C was significantly less than that in Group A and Group B (22.21 ± 4.01 vs. 19.92 ± 4.11 vs. 17.71 ± 3.47; P < 0.001). The straight-to-cuff stylet preshape angulation of curvature of the blade could provide a higher FPS rate and shorter time to tracheal intubation during video laryngoscopy-assisted endotracheal intubation. Trial registration: Chinese Clinical Trial Registry, ChiCTR1900026019.

A test prototype of a novel flexible video laryngoscope and preliminary verification in a difficult airway management simulator

Background

To verify a test prototype of a novel flexible video laryngoscope in a difficult airway management simulator and to compare the efficacy of the flexible video laryngoscope with that of a conventional video laryngoscope.

Methods

Fifteen clinical anesthesiologists performed endotracheal intubation with a flexible video laryngoscope and a conventional video laryngoscope in a difficult airway management simulator in the neutral position with intermediate and difficult mouth opening. The rate of intubation success, intubation time, and classification of glottic exposure were recorded. After endotracheal intubation, participants were asked to assess the difficulty of intubation of the two laryngoscopes.

Results

The success rate of endotracheal intubation with flexible video laryngoscope was significantly higher than that with video laryngoscope in neutral positions with both intermediate (P = 0.025) and difficult (P = 0.005) mouth opening. The Cormack Lehane score of the flexible video laryngoscope was significantly lower than that of the video laryngoscope in the neutral position with intermediate mouth opening (P < 0.001) and difficult mouth opening (P < 0.001). There was no significant difference in intubation time in the neutral position with intermediate mouth opening (P = 0.460) or difficult mouth opening (P = 0.078). The difficulty score of endotracheal intubations with the flexible video laryngoscope was also significantly lower than that of the video laryngoscope in the neutral position with intermediate mouth opening (P = 0.001) and difficult mouth opening (P = 0.001).

Conclusions

Compared with conventional video laryngoscopy, flexible video laryngoscopy can provide superior glottic exposure and improve the success rate of intubation in a difficult airway management simulator.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12938-022-01043-1.

The relationship between years of anesthesia experience and first-time intubation success rate with direct laryngoscope and video laryngoscope in infants: a retrospective observational study

Purpose

Studies in adults have reported that video laryngoscope is more useful than direct laryngoscope when training less experienced anesthesiologists. However, whether this is true for infants remains unclear. Therefore, this study aimed to evaluate whether the use of video laryngoscope would result in smaller differences in success rate according to anesthesiologists’ expertise than those in direct laryngoscope.

Methods

Medical records and video recordings from the operating room of patients aged < 1 year who underwent non-cardiac surgery between March 2019 and September 2021 were reviewed. Tracheal intubations between April 8, 2020, and June 20, 2021, were excluded due to the shortage of video laryngoscope blades during the COVID-19 pandemic. Rates of first-time tracheal intubation success were compared by years of anesthesia experience and initial intubation device.

Results

In total, 125 of 175 tracheal intubations were analyzed (direct laryngoscope group, n = 72; video laryngoscope group, n = 53). The first-time tracheal intubation success rate increased with years of experience as an anesthesiologist in the direct laryngoscope group (odds ratio OR 1.70, 95% confidence interval CI 1.15, 2.49; P = 0.0070), but not the video laryngoscope group (OR 0.99, 95% CI 0.74, 1.35; P = 0.99).

Conclusion

The differences in success rate according to the anesthesiologists’ years of experience were non-significant when using video laryngoscope in infants, compared to those in direct laryngoscope.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00540-022-03106-y.

Airway management of COVID-19 patients: A survey on the experience of 1125 physicians in Spain

BACKGROUND

We explored the experience of clinicians from the Spanish Society of Anesthesiology (SEDAR) in airway management of COVID-19 patients.

METHODS

An software-based survey including a 32-item questionnaire was conducted from April 18 to May 17, 2020. Participants who have been involved in tracheal intubations in patients with suspected or confirmed COVID-19 infection were included anonymously after obtaining their informed consent. The primary outcome was the preferred airway device for tracheal intubation. Secondary outcomes included the variations in clinical practice including the preferred video laryngoscope, plans for difficult airway management, and personal protective equipment.

RESULTS

1125 physicians completed the questionnaire with a response rate of 40,9%. Most participants worked in public hospitals and were anesthesiologists. The preferred device for intubation was the video laryngoscope (5.1/6), with the type of device in decreasing order as follows: Glidescope, C-MAC, Airtraq, McGrath and King Vision. The most frequently used device for intubation was the video laryngoscope (70,5%), using them in descending order as follow: the Airtraq, C-MAC, Glidescope, McGrath and King Vision. Discomfort of intubating wearing personal protective equipment and the frequency of breaching a security step was statistically significant, increasing the risk of cross infection between patients and healthcare workers. The opinion of senior doctors differed from younger physicians in the type of video-laryngoscope used, the number of experts involved in tracheal intubation and the reason that caused more stress during the airway management.

CONCLUSIONS

Most physicians preferred using a video-laryngoscope with remote monitor and disposable Macintosh blade, using the Frova guide.

Macintosh laryngoscope and i-view™ and C-MAC® video laryngoscopes for tracheal intubation with an aerosol box: a randomized crossover manikin study

Background

We tested the hypothesis that the C-MAC® video laryngoscope (C-MAC) with an external display is more useful than the disposable i-view™ video laryngoscope (i-view) with an integrated display or a Macintosh direct laryngoscope (Macintosh) for tracheal intubation with an aerosol box.

Methods

In this randomized, crossover manikin study, we recruited 37 medical personnel with > 2 years of dedicated anesthesia experience from five hospitals. After the three successful intubations within 60 s using each laryngoscope without a box, the participants performed tracheal intubation thrice with each laryngoscope with at least 2-h intervals in a determined order. The primary outcome was the intubation time. The secondary outcomes were success rate, Cormack-Lehane grade, and subjective difficulty scale score.

Results

Thirty-seven personnel (11 women and 26 men) with 12 [5–19] (median [interquartile range]) years of anesthesia and intensive care experience were enrolled. There was no significant difference in the intubation time: 30 [26–32] s for Macintosh, 29 [26–32] s for i-view, and 29 [25–31] s for C-MAC (P = 0.247). The success rate was 95–100%, without a significant difference (P = 0.135). The i-view and C-MAC exhibited superior Cormack-Lehane grades and lower subjective difficulty scale scores than the Macintosh; however, there were no differences between the i-view and C-MAC.

Conclusions

Rapid and highly successful tracheal intubation was possible with both Macintosh, i-view, and C-MAC on a normal airway manikin in an aerosol box. Improved Cormack-Lehane grade and the ease of performing the procedure may support the use of video laryngoscopes.

Trial registration

UMIN Clinical Trials Registry, UMIN000040269. Registered 30 April 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40981-021-00455-7.

Evaluation of a curved surgical prototype in a human larynx

Purpose

It is not always possible to create linear access to the larynx using a rigid operating laryngoscope for microlaryngoscopy. In this study, we evaluate the usability of a novel curved surgical prototype with flexible instruments for the larynx (sMAC) in a simulation dummy and human body donor.

Methods

In a user study (n = 6), head and neck surgeons as well as medical students tested the system for visualization quality and accessibility of laryngeal landmarks on an intubation dummy and human cadaver. A biopsy of the epiglottis was taken from the body donor. Photographic and time documentation was carried out.

Results

The sMAC system demonstrated general feasibility for laryngeal surgery. Unlike conventional microlaryngoscopy, all landmarks could be visualized and manipulated in both setups. Biopsy removal was possible. Visibility of the surgical field remained largely unobstructed even with an endotracheal tube in place. Overall handling of the sMAC prototype was satisfactorily feasible at all times.

Conclusion

The sMAC system could offer an alternative for patients, where microlaryngoscopy is not applicable. A clinical trial has to clarify if the system benefits in clinical routine.

The hospital difficult airway team: experience and implications for patient care

The difficult airway involves the complex interaction between patient factors, the clinical setting and the practitioner's skills (Apfelbaum in Anesthesiology 118(2):251-70, 2013 and Mark et al. in Anesth Analg 121(1):127-139, 2015). It can also be a result of preparedness and system failures. Our institution developed a protocol to enhance emergency airway management in settings outside of the operating theatre-the difficult airway (DA) team. The aims of this report are to perform a retrospective review to describe the patient profiles as well as our difficult airway code workflow, and to identify preliminary patterns within DAC activations over an 18-month period (September 2013 to November 2015) in a tertiary university hospital. We believe that these findings may aid institutions in establishing a difficult airway protocol or refining existing airway code workflows. Institutional board approval was granted for medical record review.

Combined Use of a Gum Elastic Bougie and Video Laryngoscopy for Intubating a Patient With an Unexpected Laryngeal Papilloma

This is a case report of a 75-year-old man scheduled for apical resection and cystectomy of odontogenic cysts involving both maxillary central incisors who presented with a previously unknown laryngeal mass that was discovered prior to intubation. Following induction and easy mask ventilation, direct laryngoscopy revealed a large mass on the right side of the glottis that impeded passage of a standard oral endotracheal tube. Successful atraumatic intubation was performed with the combination of a video laryngoscope (King Vision, Ambu Inc, Ballerup, Denmark) and a gum elastic bougie (GEB). Although a GEB may not be used routinely for tracheal intubation, it facilitated smooth advancement of the endotracheal tube without damaging the laryngeal mass when used in combination with video laryngoscopy.

Comparison of TruView and King Vision video laryngoscopes in subaxial cervical spine injury: A randomized controlled trial

Background:

Airway management with cervical spine immobilization poses a particular challenge for intubation in the absence of neck extension and risks neurological damage in cases of unstable cervical spine injuries. Here, with manual inline stabilization (MILS) in patients with cervical spine injuries, we compared the safety/efficacy of intubation utilizing the TruView versus King Vision video laryngoscopes.

Methods:

This prospective, single-blind, comparative study was conducted over a 3-year period. The study population included 60 American Society of Anesthesiologists (ASA) Grade I-III patients, aged 18–65 years, who underwent subaxial cervical spine surgery utilizing two intubation techniques; TruView (TV) versus King Vision (KV). For both groups, relative intubation difficulty scores (IDS), total duration of intubation, hemodynamic changes, and other complications (e.g., soft-tissue injury and neurological deterioration) were recorded.

Results:

With MILS, patients in the KV group had statistically significant lower IDS (0.70 ± 1.02) and significantly shorter duration of intubation as compared to the TV group (1.67 ± 1.27) with MILS (P = 0.0010); notably, the glottic exposure was similar in both groups. The complication rate (e.g., soft-tissue injury) was lower for the KV group, but this was not statistically significant. Interestingly, no patient from either group exhibited increased neurological deterioration attributable to the method of intubation.

Conclusion:

King Vision has several advantages over TruView for intubating patients who have sustained cervical spine trauma. Nevertheless, both laryngoscopes afford comparable glottic views and safety profiles with similar alterations in hemodynamics.

Clinical diagnosis and treatment of throat foreign bodies under video laryngoscopy

Objective

This study was designed to explore the clinical application of video laryngoscopy in the diagnosis and treatment of throat foreign bodies (FBs).

Method

In total, 1572 patients diagnosed with throat FBs at the Department of Otolaryngology of Nanjing Drum Tower Hospital were retrospectively analysed. The covariables collected were the time from FB ingestion to admission, age, sex, duration of admission, and site of impaction.

Result

The most common FBs were fish bones, which accounted for 1446 (91.98%) of 1572 FBs. Among all 1572 FBs, 1004 (63.87%) were successfully removed by video laryngoscopy without complications. A shorter duration of admission was associated with a higher diagnostic rate under video laryngoscopy. The diagnostic rate of sharp FBs was significantly higher than that of non-sharp FBs. The most common sites of throat FBs were the tongue root (42.29%), epiglottic vallecula (19.40%), tonsil (18.21%), and piriform fossa (10.65%).

Conclusion

Video laryngoscopy is a powerful tool for the diagnosis and treatment of throat FBs, allowing for identification of rare locations of FBs as well as refractory FBs.

Concurrent Use of Videolaryngoscope and Fiberoptic Bronchoscope in a Child with Neurofibromatosis to Facilitate Endotracheal Intubation

INTRODUCTION

In children who have craniofacial asymmetry secondary to neurofibromatosis type 1, the securing of the airway can be challenging. These patients have varying degrees of head and neck tumors that complicate endotracheal intubation. Anesthesiologists have many techniques and devices that assist us in securing adult airways and these devices are available in pediatric sizes which can also be used to safely secure the smaller airways.

CASE

This 13-year-old male patient with Neurofibromatosis presented with a 2 cm mouth opening, Mallampati IV assessment, and thyromental distance of 2 cm for surgery. During the previous management of this child's airway it was found to be difficult using the fiberoptic bronchoscope or the Glidescope alone.

DISCUSSION

This is a case report of improvement of intubating conditions using both devices concurrently.

Lower maximum forces on oral structures when using gum-elastic bougie than when using endotracheal tube and stylet during both direct and indirect laryngoscopy by novices: a crossover study using a high-fidelity simulator

BACKGROUND

Applying excessive force during endotracheal intubation (ETI) is associated with several complications, including dental trauma and hemodynamic alterations. A gum-elastic bougie (GEB), a type of tracheal tube introducer, is a useful airway adjunct for patients with poor laryngoscopic views. However, how the use of a GEB affects the force applied during laryngoscopy is unclear. We compared the force applied on the oral structures during ETI performed by novices using the GEB versus an endotracheal tube + stylet.

METHODS

This prospective crossover study was conducted from April 2017 to March 2019 in a public medical university in Japan. In total, 209 medical students (4th and 5th grade, mean age of 23.7 ± 2.0 years) without clinical ETI experience were recruited. The participants used either a Macintosh direct laryngoscope (DL) or C-MAC video laryngoscope (VL) in combination with a GEB or stylet to perform ETI on a high-fidelity airway management simulator. The order of the first ETI method was randomized to minimize the learning curve effect. The outcomes of interest were the maximum forces applied on the maxillary incisors and tongue during laryngoscopy. The implanted sensors in the simulator quantified these forces automatically.

RESULTS

The maximum force applied on the maxillary incisors was significantly lower when using a GEB than when using an endotracheal tube + stylet both with the Macintosh DL (39.0 ± 23.3 vs. 47.4 ± 32.6 N, P < 0.001) and C-MAC VL (38.9 ± 18.6 vs. 42.0 ± 22.1 N, P < 0.001). Similarly, the force applied on the tongue was significantly lower when using a GEB than when using an endotracheal tube + stylet both with the Macintosh DL (31.9 ± 20.8 vs. 37.8 ± 22.2 N, P < 0.001) and C-MAC VL (35.2 ± 17.5 vs. 38.4 ± 17.5 N, P < 0.001).

CONCLUSIONS

Compared with the use of an endotracheal tube + stylet, the use of a GEB was associated with lower maximum forces on the oral structures during both direct and indirect laryngoscopy performed by novices. Our results suggest the expanded role of a GEB beyond an airway adjunct for difficult airways.

Intubation in the Intensive Care Unit: C-MAC video laryngoscope versus Macintosh laryngoscope

PURPOSE

Various modifications of the Macintosh blade and direct laryngoscopy have been incorporated into practice to improve the intubation success rate and avoid complications while ensuring patient safety. This study evaluates the usefulness of two different direct laryngoscopy methods used by operators with various level of experience in the Intensive Care Unit.

MATERIAL AND METHODS

In a single centre prospective study, C-MAC and Macintosh laryngoscopes were compared in terms of laryngoscopy and intubation outcomes such as glottic visualization, number of intubation attempts, intubation success and satisfaction score.

RESULTS

During the one-year study period, 263 patients were evaluated and data of 218 patients were analyzed. The rate of successful first attempt intubation was higher in the video laryngoscope group (VL) (84% vs 57%; P<0.001). A significantly greater number of patients in the Macintosh laryngoscopy group had difficult visualization of the glottis in terms of the modified Cormack and Lehane classification and Percentage of Glottic Opening scale.

CONCLUSION

The use of video laryngoscope for intubation in ICU settings results in better visualization of the glottis and a higher incidence of successful intubation attempts.

Endotracheal Intubation Complicated by a Palatal Tooth in a Patient With Treacher Collins Syndrome

We report a case of difficult endotracheal intubation in a patient with Treacher Collins syndrome. A sixteen-year-old female patient scheduled for general anesthesia had a displaced palatal tooth that interfered with laryngoscope insertion into the pharyngeal space. To address this problem, we successfully performed endotracheal intubation using a fiberscope while elevating the epiglottic vallecula using a King Vision™ video laryngoscope. A later operation was performed after tooth extraction without difficult laryngoscopy. Our experience stresses the importance of removing obstructions to laryngoscopic inspection prior to general anesthesia.

Comparison of cervical spine motion during intubation with a C‑MAC D‑Blade® and an LMA Fastrach®

BACKGROUND

This prospective randomized study compared cervical motion during intubation with a C‑MAC D‑Blade® and with a laryngeal mask airway LMA Fastrach®.

MATERIAL AND METHODS

The participants in this study were 52 ASA I-III patients aged 18-70 years and assigned for elective cervical discectomy. The patients were randomly selected for intubation with a C‑MAC D‑Blade® (group V) or an LMA Fastrach® laryngeal airway (group F). Both groups received the same induction of anaesthesia. The first lateral view was X‑rayed while the head and neck were in a neutral supine position and the second exposure was taken during the passage of the endotracheal tube through the vocal cords for group V and during the advance of the endotracheal tube for group F. The occiput-C1 (C0-C1), C1-C2 and C2-5 angles were measured. The angle formed by the line between the occipital protuberance and anterior process of the foramen magnum and the line between the central point of C1 spinous process and the anterior process of the foramen magnum was defined as angle A. The differences between the angles were calculated. Overall intubation success and first-pass success (success at the first attempt) were recorded.

RESULTS

The change in angulations between C0-C1 during intubation was significantly lower in group F than in group V (2.78⁰ ± 2.1⁰ vs. 6.04⁰ ± 4.1⁰, p = 0.007). Before intubation, angle A was 14.4⁰ ± 3.9⁰ in group V and 13.8⁰ ± 3.7⁰ in group F (p = 0.627). During intubation, angle A was significantly smaller for group V than for group F (9.1⁰ ± 2.4⁰ vs. 10.7⁰ ± 2.9⁰, p = 0.04). The number of successful intubations were significantly higher in group V (100% of intubations were successful on the first attempt for group V, vs. 80% for group F, p = 0.023).

CONCLUSION

Intubation with both a C‑MAC D‑Blade and a Fastrach LMA resulted in cervical motion but within safe ranges. Intubation with a C-mac D blade might be preferred because the Fastrach LMA may result in more failed intubation attempts in patients with cervical spine disorders.

Improving pediatric resident laryngoscopy training through the use of a video laryngoscope

IMPORTANCE

Opportunities for pediatric residents to perform direct laryngoscopy and tracheal intubation (DLTI) are few and the success rate is low.

OBJECTIVE

We hypothesize that incorporation of video laryngoscope (McGrath MAC) into pediatric residents DLTI simulation course will improve the simulated DLTI success rate.

METHODS

Residents were given 3 attempts at DLTI: (1) baseline using a conventional laryngoscope (CL); (2) using a video laryngoscope (VL); and (3) again using the CL. Residents were given up to 120 seconds to complete each DLTI attempt. Time to successful DLTI was collected. Residents recorded their best view (larynx, epiglottis, vocal cords) with each DLTI attempt.

RESULTS

Prior to the intervention, 15/17 (88.2%) and 16/17 (94.1%) of the participants reported prior exposure to DLTI as "less than 10 total attempts" in simulated and live patients respectively. Seventeen pediatric residents performed 51 DLTI attempts (34 with a CL and 17 with the VL). Success rates for DLTI are as follows: Baseline with CL 11/17 (64.7%), VL 12/17 (70.6%), and last attempt with CL 13/17 (76.5%) (P = 0.15). Compared to the baseline, the use of VL resulted in a shorter but non-significant decrease in time to successful DLTI (Mean 34.2 sec [SD, 22.0] vs. 56.5 sec [SD, 40.2]; P = 0.08). Repeat attempts at DLTI with the CL, however, were significantly shorter than baseline (Mean 20.3 sec [SD, 12.8] vs. 56.5 sec [SD, 40.2]; P = 0.003). Using the VL, more residents could visualize the vocal cords compared to the baseline (14/17 [82.3%] vs. 9/17 [52.9%]; P = 0.03).

INTERPRETATION

Repeated training is certainly a way to improve successful DLTI. Use of VL as a new teaching method led to greater visualization of the vocal cords, shortening operating time and raising self-confidence.

Change in management of predicted difficult airways following introduction of video laryngoscopes

AIM

To determine if video laryngoscopy (VL) has significantly impacted management of difficult airways by decreasing the rate of awake fiberoptic intubation (FOI).

METHODS

Anesthetic records of 3723 patients who underwent general anesthesia at Rush University Medical Center were reviewed over a 2-mo period prior to the introduction of VLs in 2009 (“pre-VL” group) and over the same 2-mo period after the introduction of VLs in 2012 (“post-VL” group). Patient records with predicted difficult airways based on pre-operative airway examination were analyzed. The primary outcome was rate of awake FOI.

RESULTS

To control for possible factors that may influence the FOI rate, a logistic regression was performed with these factors included as covariates. The rate of awake FOI was 13.1% in pre-VL group compared to 9.0% in post-VL group. Although this decrease was not statistically significant individually (P = 0.1768), it showed a trend toward significance when covariates were accounted for (P = 0.0910). Several factors predicting a higher likelihood of awake FOI were found to be statistically significant: Morbid obesity (larger BMI P = 0.0154, OR = 1.5 per 10 point BMI increase), male gender (P = 0.0026, OR = 3.0) and a higher el-Ganzouri airway score (P = 0.0007, OR = 1.5). Although VLs were seen to be used to intubate 51% of predicted difficult airways, the rate of awake FOI has not significantly changed.

CONCLUSION

Although VL may continue to grow in popularity, the most difficult airways are still managed using awake FOI.

A comparison between video laryngoscopy and direct laryngoscopy for endotracheal intubation in the emergency department: A meta-analysis of randomized controlled trials

STUDY OBJECTIVES

Direct laryngoscopy is the most commonly used modality for endotracheal intubation in the emergency department. Video laryngoscopy may improve glottic view during laryngoscopy and intubation success rate in such patients. This meta-analysis has been designed to compare clinical efficacy of video laryngoscopy with direct laryngoscopy for endotracheal intubation in the emergency department.

DESIGN

Meta-analysis of randomized controlled trial.

SETTING

Randomized controlled trials comparing video laryngoscopy and direct laryngoscopy for endotracheal intubation in adult patients in emergency department. PubMed (1946 to 20th October 2017) and The Cochrane Library databases (CENTRAL) were searched for potentially eligible trials on 20th October 2017.

PATIENTS

Adult patients presenting in the emergency department.

INTERVENTIONS

Video laryngoscopy & direct laryngoscopy for intubation in emergency department.

MEASUREMENT

Primary outcome was 'first intubation success rate' and secondary outcomes were overall intubation success rate, in-hospital mortality and oesophageal intubation rate.

MAIN RESULTS

Data of 1250 patients from 5 randomized controlled trials have been included in this study. Video laryngoscopy offers no advantage over direct laryngoscopy in terms of first intubation success rate (odds ratio 1.28, 95% CI 0.70, 2.36; p = 0.42), overall intubation success rate (OR 1.26, 95% CI 0.53, 3.01; p = 0.6) or in-hospital mortality (OR 1.25, 95% CI 0.8, 1.95; p = 0.32). However, oesophageal intubation rate is lower with the use of video laryngoscopy (OR 0.09, 95% CI 0.01, 0.7; p = 0.02).

CONCLUSION

Use of video laryngoscopy for emergency endotracheal intubation in adult patients is associated with reduced oesophageal intubation over direct laryngoscopy. However, no benefit was found in terms of overall intubation success.

Nasogastric tube placement with video-guided laryngoscope: A manikin simulator study

BACKGROUND

This study aimed to investigate video-guided laryngoscopy for nasogastric tube placement.

METHODS

This was an observational comparative study performed in a hospital. The participants included volunteers from the medical staff (physicians and nurses) experienced with nasogastric intubation, and non-medical staff (medical students, pharmacists and emergent medical technicians) with knowledge of nasogastric intubation but lacking procedural experience. Medical and non-medical hospital staff performed manual, laryngoscope-assisted and video-guided laryngoscope nasogastric intubation both in the presence and in the absence of an endotracheal tube, using a manikin. Nasogastric intubation times were compared between groups and methods.

RESULTS

Using the video-guided laryngoscope resulted in a significantly shorter intubation time compared to the other 2 methods, both with and without an endotracheal tube, for the medical and non-medical staff alike (all p < 0.05). For the medical staff, mean nasogastric intubation time was significantly shorter using video-guided laryngoscope without endotracheal intubation, direct laryngoscope with endotracheal intubation and video-guided laryngoscope with endotracheal intubation compared to manual intubation without endotracheal intubation (0.49, 0.63 and 0.72 vs. 5.63, respectively, p ≤ 0.008). For non-medical staff, nasogastric intubation time was significantly shorter using video-guided laryngoscope without endotracheal intubation, direct laryngoscope with endotracheal intubation and video-guided laryngoscope with endotracheal intubation compared to manual intubation without endotracheal intubation (1.67, 1.58 and 0.95 vs. 6.9, respectively, p ≤ 0.002). And mean nasogastric intubation time for video-guided laryngoscope endotracheal intubation was significantly shorter for medical staff than for non-medical staff (0.49 vs. 1.67 min, respectively, p = 0.041).

CONCLUSION

Video-guided laryngoscope reduces nasogastric intubation time compared to manual and direct laryngoscope intubation, which promotes a consistent technique when performed by experienced medical and previously untrained non-medical staff.

[Comparison of different methods of nasogastric tube insertion in anesthetized and intubated patients]

BACKGROUND

Nasogastric tube insertion may be difficult in anesthetized and intubated patients with head in the neutral position. Several techniques are available for the successful insertion of nasogastric tube. The primary aim of this study was to investigate the difference in the first attempt success rate of different techniques for insertion of nasogastric tube. Secondary aim was to investigate the difference of the duration of insertion using the selected technique, complications during insertion such as kinking and mucosal bleeding.

MATERIAL AND METHODS

200 adult patients, who received general anesthesia for elective abdominal surgeries that required nasogastric tube insertion, were randomized into four groups: Conventional group (Group C), head in the lateral position group (Group L), endotracheal tube assisted group (Group ET) and McGrath video laryngoscope group (Group MG). Success rates, duration of insertion and complications were noted.

RESULTS

Success rates of nasogastric tube insertion in first attempt and overall were lower in Group C than Group ET and Group MG. Mean duration and total time for successful insertion of NG tube in first attempt were significantly longer in Group ET. Kinking was higher in Group C. Mucosal bleeding was statistically lower in Group MG.

CONCLUSION

Use of video laryngoscope and endotracheal tube assistance during NG tube insertion compared with conventional technique increase the success rate and reduce the kinking in anesthetized and intubated adult patients. Use of video laryngoscope during nasogastric tube insertion compared to other techniques reduces the mucosal bleeding in anesthetized and intubated adult patients.

Airway management for glossopexy in infants with micrognathia and obstructive breathing

STUDY OBJECTIVES

To identify airway management and tracheal intubation techniques for glossopexy in infants with preexisting airway obstruction under general anesthesia.

DESIGN

Retrospective, observational study.

SETTINGS

Operating room of a university hospital between January 2003 and March 2015. All operations were performed by oral and maxillofacial surgeons.

PATIENTS

Thirteen patients who received general anesthesia for glossopexy and reversal after 7 months.

MEASUREMENTS

The medical records of these infants were retrospectively examined to evaluate the following: age, sex, height and weight at surgery, preoperative airway status, tracheal intubation route (oral or nasal), method for inducing general anesthesia, method for establishing the airway during mask ventilation, apparatus used for tracheal intubation, Cormack-Lehane classification when using a Macintosh laryngoscope and video laryngoscope, and the need for airway placement after extubation.

RESULTS

Prone positioning and/or an airway of some kind before surgery were required in 38.5% of infants needing glossopexy. Difficult mask ventilation was common, occurring in 50% of the patients, and the incidence of airway placement during mask ventilation was significantly higher in infants with preoperative complete or incomplete obstruction (100%) than in infants with snoring (25%). Of these high-risk infants, 25% could not be intubated with a direct laryngoscope or Glidescope Cobalt and required fiberoptic intubation.

CONCLUSION

There are severe cases of infants with difficult mask ventilation and difficult tracheal intubation in which a fiberscope is required because video laryngoscopy fails to improve the view of the larynx.

Lingual Tonsil Hypertrophy: rescuing the airway with videolaryngoscopy

Lingual tonsils are lymphatic tissues located at the base of the tongue that may hypertrophy causing difficulty and sometimes inability to ventilate or intubate during anesthesia. Routine airway assessment fails to diagnose lingual tonsil hypertrophy. There is limited experience with use of videolaryngoscopy in cases of lingual tonsil hypertrophy. We present a case of difficult airway due to unanticipated lingual tonsil hypertrophy successfully managed by atypical video laryngoscope positioning.

Comparison between the Trachway video intubating stylet and Macintosh laryngoscope in four simulated difficult tracheal intubations: A manikin study

OBJECTIVES

It remains to be determined whether the TVI-4000 Trachway video intubating (TVI) stylet (Markstein Sichtec Medical Corp, Taichung, Taiwan), an airway device for novices, improves airway management practice by experienced anesthesiologists. The aim of this study was to evaluate the feasibility of using the TVI stylet in difficult tracheal intubation situations compared with that of using the Macintosh laryngoscope on an airway manikin.

MATERIALS AND METHODS

Ten anesthesiologists (with 3-21 years' experience), including three senior residents, participated. We compared tracheal intubation in four airway scenarios: normal airway, tongue edema, cervical spine immobilization, and tongue edema combined with cervical spine immobilization. The time of tracheal intubation (TTI), success rate, and perceived difficulty of intubation for each scenario were compared and analyzed.

RESULTS

The TTI was significantly shorter in both the tongue edema and combined scenarios with the TVI stylet compared with the Macintosh laryngoscope (21.60 ± 1.45 seconds vs. 24.07 ± 1.58 seconds and 23.73 ± 2.05 seconds vs. 26.6 ± 2.77 seconds, respectively). Success rates for both devices were 100%. Concomitantly, participants rated using the TVI stylet in these two scenarios as being less difficult.

CONCLUSION

The learning time for tracheal intubation using the TVI stylet in difficult airway scenarios was short. Use of the TVI stylet was easier and required a shorter TTI for tracheal intubation in the tongue edema and combined scenarios.

Double-lumen tube intubation using video laryngoscopy causes a milder cardiovascular response compared to classic direct laryngoscopy

Objective:

To determine whether there is a clinically relevant difference between the circulatory responses to double-lumen tube intubation (DLTI) with the GlideScope video laryngoscope versus the Macintosh direct laryngoscope.

Methods:

Eighty adult patients requiring double-lumen tubes for thoracic surgery were randomly and equally allocated to either a Macintosh direct laryngoscope group (DL group, n = 40) or a Glide Scope video laryngoscope group (GS group, n = 40). DLTI was performed after airway evaluations and induction of anesthesia. Systolic blood pressure (SBP) and heart rate (HR) were recorded before induction (baseline values), immediately before intubation (post-induction values), at intubation and after intubation. Rate-pressure-product (RPP), and the areas under SBP- and HR-time curves were calculated. All data obtained by the two devices were compared.

Results:

After laryngoscope insertion, SBP of DL and GS groups changed significantly differently (13.1% vs. 4.6%, P< 0.001), while HR changed similarly (17.2% vs. 14.6%, P = 0.074). One minute after intubation, both SBP and HR significantly increased in both groups (SBP: 11.6% vs. 11.9%; HR: 18.4% vs. 10.8%), but there were no significant differences between the two groups. RPP significantly increased in both groups after laryngoscope insertion (32.6%, P=0.001; 18.2%, P=0.002), and there was a significant difference between the two groups (P =0.001). Throughout intubation, the areas under SBP-time curves had a significant difference between the two groups (P = 0.042), while those under HR-time curves did not differ significantly (P=0.06).

Conclusion:

The intubation response was most significant upon laryngoscope insertion during the whole intubation process. The GlideScope video laryngoscope induced milder circulatory fluctuations than the Macintosh direct laryngoscope did, suggesting that DLTI using video laryngoscopy can help reduce the cardiovascular response to intubation.

Comparison of the C-MAC video laryngoscope to the Macintosh laryngoscope for intubation of blunt trauma patients in the ED

Objectives

We aimed to compare the performance of the C-MAC video laryngoscope (C-MAC) to the Macintosh laryngoscope for intubation of blunt trauma patients in the ED.

Material and methods

This was a prospective randomized study. The primary outcome measure is overall successful intubation. Secondary outcome measures are first attempt successful intubation, Cormack–Lehane (CL) grade, and indicators of the reasons for unsuccessful intubation at the first attempt with each device. Adult patients who suffered from blunt trauma and required intubation were randomized to video laryngoscopy with C-MAC device or direct laryngoscopy (DL).

Results

During a 17-month period, a total of 150 trauma intubations were performed using a C-MAC and DL. Baseline characteristics of patients were similar between the C-MAC and DL group. Overall success for the C-MAC was 69/75 (92%, 95% CI 0.83 to 0.96) while for the DL it was 72/75 (96%, 95% CI 0.88 to 0.98). First attempt success for the C-MAC was 47/75 (62.7%, 95% CI 0.51 to 0.72) while for the DL it was 44/75 patients (58.7%, 95% CI 0.47 to 0.69). The mean time to achieve successful intubation was 33.4 ± 2.5 s for the C-MAC versus 42.4 ± 5.1 s for the DL (p = 0.93). There was a statistically significant difference between the DL and C-MAC in terms of visualizing the glottic opening and esophageal intubation in favor of the C-MAC (p = 0.002 and p = 0.013 respectively).

Discussion and conclusion

The overall success rates were similar. The C-MAC demonstrated improved glottic view and decrease in esophageal intubation rate.

A case of unexpectedly difficult intubation caused by a large asymptomatic choanal polyp

We report a case of unexpectedly difficult intubation in a patient with a huge but asymptomatic choanal polyp. A 77-year-old man with invasive bladder cancer was scheduled for total cystectomy under general anesthesia. However, tracheal intubation with a Macintosh laryngoscope proved impossible due to obstruction by a large oropharyngeal tumor. Using a video laryngoscope, intubation was successfully achieved. Choanal polyps are not uncommon, but large choanal polyps reaching the oropharynx appear relatively rare. Anesthesia and airway management for large oropharyngeal tumor has not been sufficiently discussed.

[Educational suitability of endotracheal intubation using a video-laryngoscope]

PURPOSE

The purpose of this study is to determine the educational suitability of the video-laryngoscope in teaching endotracheal intubation to students.

METHODS

Medical students participated in a course on the use of a Macintosh direct laryngoscope and McGrath MAC videolaryngoscope for intubation. The course comprised a 1-hour lecture and 30 minutes of practice on a manikin. After the course, in each of the three simulated patient scenarios-normal airway, cervical spine fixation, and tongue edema-time to intubate, success rate, and chance of complications were measured. A questionnaire was administered before and after the course to determine thesuitability of intubation by video-laryngoscope for a medical education course. Also, changes in the perception and stance on the video-laryngoscope were evaluated.

RESULTS

Time to intubate decreased as attempts were repeated. The first-attempt success rate in the cervical spine fixation scenario was higher using the video-laryngoscope (p=0.028). Rates if tooth injury were lower in the cervical spine fixation (p=0.005) andtongue edema scenarios (p=0.021) using the video-laryngoscope. Based on the questionnaires, students responded positively with regard to their knowledge of the video-laryngoscope, its practical value, and its suitability for medical education (p<0.001). Also,the preference for the video-laryngoscope was greater (p=0.044). Students felt that repeated attempts and feedback on intubation were helpful.

CONCLUSION

The students' evaluations and surveys showed positive results to intubation by video-laryngoscope. Thus, based on its suitability for medical education it is reasonable to consider learning intubation using the video-laryngoscope.

GlideScope Video Laryngoscope for Difficult Intubation in Emergency Patients: a Quasi-Randomized Controlled Trial

Macintosh direct laryngoscope has been the most widely used device for tracheal intubation. GlideScope video laryngoscope (GVL) has been recently introduced as an alternative device for performing intubation; however, its validity in emergency settings has not been thoroughly evaluated. The aim of this study was to compare Macintosh direct laryngoscope versus GVL for emergency endotracheal intubation. This quasi-randomized clinical trial was performed on 97 patients referred to Imam Reza Hospital whom all needed emergency intubation in 2011. Patients were divided into two groups of the easy airway and difficult airway; intubation was performed for patients with direct laryngoscopy or GVL. Then, the patients were evaluated in terms of demographic characteristics, successful intubation rate and intubation time. Data was analyzed by SPSS software 16. There was no significant difference in demographic characteristics of the patients in both easy airway and difficult airway groups who intubated with direct laryngoscopy and GVL methods (P>0.05). In difficult airway group, a significant difference was found in successful intubation at the first attempt (60.9% vs. 87.5%; P=0.036), overall intubation time (32.7 ± 14.58 vs. 22.5±7.88; P<0.001) and first attempt intubation time (28.43 ± 12.51 vs. 21.48±7.8; P=0.001) between direct laryngoscopy and GVL. These variables were not significantly different between two methods in easy airway group. According to the results, GVL can be a useful alternative to direct laryngoscopy in emergency situations and especially in cases with a difficult airway.

[Management of difficult airway with inhalation induction in a patient with Lennox-Gastaut syndrome and neck injury]

Lennox-Gastaut syndrome is a childhood epileptic encephalopathy, and is characterized by frequent and difficult to treat seizures associated with mental retardation. The case is presented of a 21 year-old male with Lennox-Gastaut syndrome, with bilateral cervical facet joint dislocation fracture at C6-C7 and spinal canal compression as a result of a fall during a seizure. In this case the management of the difficult airway expected in an awake and uncooperative patient, with cervical spinal cord injury is described. An airway management strategy was proposed, that allowed a rapid and safe airway control with the best possible tolerance and maintaining the neck immobilised, so as not to increase neurological injury. Within this strategy, plan A was defined as inhalation induction with sevoflurane to maintain spontaneous breathing and tracheal intubation with Airtraq®. We believe that the Airtraq® video laryngoscope with inhalational induction with sevoflurane is a valid and effective alternative in the management of expected difficult airway.

Gastric tube insertion under direct vision using the King Vision™ video laryngoscope: a randomized, prospective, clinical trial

Background

The frequency of malpositioning of gastric tubes in the trachea has been reported to be 0.3–15%, which may cause severe complications, such as pneumonia, if not detected promptly. If a gastric tube can be guided into the esophagus under direct vision with a video laryngoscope, misplacement of the gastric tube into the trachea can be avoided. We compared gastric tube insertion under direct vision using a video laryngoscope with the conventional method of blind insertion.

Methods

We enrolled 60 patients who required a transnasal gastric tube to facilitate elective abdominal surgery under general anesthesia. The participants were recruited consecutively into one of two groups, a group of 30 patients in whom a gastric tube was inserted using a King Vision™ video laryngoscope (KV group), and a group of 30 patients who underwent conventional blind insertion of the gastric tube (Blind group). The success rate, the time taken to insert the gastric tube, and the incidence of complications were compared.

Results

In the KV group, the time required for gastric tube placement was 52.5 ± 17.1 seconds, with a success rate of 100%. Slight oral hemorrhage occurred in two participants and slight epistaxis in one participant. In the Blind group, the time required for gastric tube placement was 65.9 ± 39.9 seconds, with a success rate of 90% (27 out of 30 patients). Slight oral hemorrhage occurred in two participants, slight epistaxis occurred in two participants, and tracheal malposition occurred in one participant but was detected promptly and corrected using the video laryngoscope. There were no significant differences in the time required for placing the gastric tube, the success rate, or the incidence of complications between the groups.

Conclusions

Gastric tube insertion using a King Vision video laryngoscope was straightforward, and was particularly useful for detecting and correcting tracheal malpositioning.

Trial registration

Trial registry number: UMIN000011014.

Comparison of Airtraq optical laryngoscope and Storz video laryngoscope in a cadaver model

BACKGROUND

Airway management in the emergency department is a critical intervention that requires both standard techniques and rescue techniques to ensure a high rate of success. Recently, video laryngoscope (VL) systems have become increasingly common in many large urban EDs, but these systems may exceed the budgets of smaller rural EDs and EMS services and the Airtraq optical laryngoscope (OL) may provide an effective, low-cost alternative. We hypothesized that laryngeal view and time to endothracheal tube placement for OL and VL intubations would not be significantly different.

METHODS

This was a prospective, crossover trial.

SETTING

University-based emergency medicine residency program procedure laboratory utilizing lightly embalmed cadavers.

SUBJECTS

PGY1-3 emergency medicine residents. The study subjects performed timed endotracheal intubations alternately using the OL and VL. The subjects then rated the Cormack-Lehane laryngeal view for each device.

STATISTICAL ANALYSIS

Mean time to intubation and the mean laryngeal view score were calculated with 95% confidence intervals and statistical significance was determined by Student's t test.

RESULTS

Fourteen subjects completed the study. The average laryngeal view achieved with the OL vs. the VL was not significantly different, with Cormack-Lehane grade of 1.14 vs. 1.07, respectively. Time to endotracheal intubation, however, was significantly different (P<0.001) with the average time to intubation for the OL 25.49 seconds (95% CI: 17.95-33.03) and the VL 13.41 seconds (10.27-16.55).

CONCLUSION

The Airtraq OL and the Storz VL yielded similar laryngeal views in the lightly embalmed cadaver model. Time to endotracheal tube placement, however, was less for the VL.

Anesthetic management for a patient with severe mento-sternal contracture: difficult airway and scarce venous access -A case report-

There are many problems in the anesthetic management of patients with scar contracture. In this case, a 41-year-old male with severe scar contracture on his face, neck, anterior chest, and both shoulders underwent surgery for resurfacing with flaps. We tried to awake fiberoptic orotracheal intubation with GlideScope® Video laryngoscope guide after surgical release of contracture under local anesthesia. We report a successful management of a patient with severe burn contracture achieved by combined effort of surgeons and anesthesiologists.

A comparative study on the efficacy and cardiovascular response generated by macintosh and pentax-AWS video laryngoscopic endotracheal intubation methods

BACKGROUND

The Pentax-AWS is a newly developed rigid video laryngoscope. In comparison to the Macintosh laryngoscope, it offers a significantly improved laryngeal view and facilitates endotracheal intubation. The present study was performed to compare the general efficiency and the cardiovascular responses generated by Macintosh and Pentax-AWS systems during endotracheal intubation.

METHODS

This study included 120 patients with American Society of Anesthesiologists (ASA) physical status class 1 or 2 requiring tracheal intubation for elective surgery. All patients were randomly allocated into two groups: Pentax-AWS (group P) and Macintosh (group M). Induction of anesthesia was performed using fentanyl, thiopental and succinylcholine intravenously. Systolic, mean and diastolic blood pressure (SBP, MBP, DBP) and heart rate (HR) were recorded just prior to induction, 1, 3, and 5 minutes after intubation.

RESULTS

There were no significant differences in SBP, MBP, DBP and HR between both groups. However, group P showed a higher POGO (Percentage of Glottic Opening) score than group M during endotracheal intubation.

CONCLUSIONS

Use of Pentax-AWS in endotracheal intubation did not increase hemodynamic changes compared to the use of Macintosh laryngoscope. Furthermore, Pentax-AWS offered an improved laryngeal view during endotracheal intubation.