A wire-reinforced silicone tube (LMA-Fastrach™ endotracheal tube) is specially designed for tracheal intubation using intubating laryngeal mask airway (ILMA). However, conventional polyvinyl chloride (PVC) tracheal tubes have also been used with ILMA to achieve tracheal intubation successfully.
To evaluate the success of tracheal intubation using the LMA-Fastrach™ tracheal tube versus conventional PVC tracheal tube through ILMA.
Settings and Design:
Two hundred adult ASA physical status I/II patients, scheduled to undergo elective surgery under general anaesthesia requiring intubation, were randomly allocated into two groups.
The number of attempts, time taken, and manoeuvres employed to accomplish tracheal intubation were compared using conventional PVC tubes (group I) and LMA-Fastrach™ wire-reinforced silicone tubes (group II). Intraoperative haemodynamic changes and evidence of trauma and postoperative incidence of sore throat and hoarseness, were compared between the groups.
The data was analyzed using two Student's t test and Chi-square test for demographics and haemodynamic parameters. Mann Whitney U test was used for comparison of time taken for endotracheal tube insertion. Fisher's exact test was used to compare postoperative complications.
Rate of successful tracheal intubation and haemodynamic variables were comparable between the groups. Time taken for tracheal intubation and manoeuvres required to accomplish successful endotracheal intubation, however, were significantly greater in group I than group II (14.71±6.21 s and 10.04±4.49 s, respectively (P<0.001), and 28% in group I and 3% in group II, respectively (P<0.05)).
Conventional PVC tube can be safely used for tracheal intubation through the ILMA.
Fastrach; intubating laryngeal mask airway; polyvinyl chloride; tracheal intubation
Laryngeal mask airway (LMA) C Trach is a novel device designed to intubate trachea without conventional laryngoscopy. The aim of the study was to evaluate the clinical efficacy of C trach in the simulated scenario of cervical spine injury where conventional laryngoscopy is not desirable.
This prospective pilot study was carried out in 30 consenting adults of either gender, ASAPS I or II, scheduled for surgery requiring endotracheal intubation. An appropriate sized rigid cervical collar was positioned around the patient's neck to restrict the neck movements and simulate the scenario of cervical spine injury. After induction of anesthesia, various technical aspects of C Trach facilitated endotracheal intubation, changes in hemodynamic variables, and complications were recorded.
Mask ventilation was easy in all the patients. Successful insertion of C Trach was achieved in 27 patients at first attempt, while 3 patients required second attempt. Majority of patients required one of the adjusting maneuvers to obtain acceptable view of glottis (POGO score >50%). Intubation success rate was 100% with 26 patients intubated at first attempt and the rest required second attempt. Mean intubation time was 69.8±27.40 sec. With experience, significant decrease in mean intubation time was observed in last 10 patients as compared to first 10 (46±15.77 sec vs. 101.3±22.91 sec). Minor mucosal injury was noted in four patients.
LMA C Trach facilitates endotracheal intubation under direct vision and can be a useful technique in patients with cervical spine injury with cervical collar in situ.
Cervical spine injury; cervical collar; laryngeal mask airway C Trach
Although the difficulty of tracheal intubation in the lateral position has not been systematically evaluated, airway loss during surgery in a laterally positioned patient may have hazardous consequences. We explored whether the intubating laryngeal mask airway (ILMA) facilitates tracheal intubation in patients with normal airway anatomy, i.e., Mallampati grade ≤ 3 and thyromental distance ≥ 5 cm, positioned in the lateral position. And we evaluated whether this technique can be used as a rescue when the airway is lost mid-case in laterally positioned patients with respect to success rate and intubation time. Anesthesia was induced with propofol, fentanyl, and vecuronium in 50 patients undergoing spine surgery for lumbar disk herniation (Lateral) and 50 undergoing other surgical procedures (Supine). Patients having disk surgery (Lateral) were positioned on their right or left sides before induction of general anesthesia, and intubation was performed in that position. Patients in control group (Supine) were anesthetized in supine position, and intubation was performed in that position. Intubation was performed blindly via an ILMA in both groups. The time required for intubation and number and types of adjusting maneuvers employed were recorded. Data were compared by Mann-Whitney U, Fisher’s exact, chi-square, or unpaired t-tests, as appropriate. Data presented as mean (SD). Demographic and airway measures were similar in the two groups, except for mouth opening which was slightly wider in patients in the lateral position: 5.1 (0.9) vs. 4.6 (0.7) cm. The time required for intubation was similar in each group (≈25 s), as was intubation success (96%). We conclude that blind intubation via an ILMA offers a frequent success rate and a clinically acceptable intubation time (< one min) even in the lateral position.
Blind intubation via the intubating laryngeal mask airway (ILMA) offers a high success rate and a clinically acceptable intubation time even in patients in the lateral position.
Equipment: intubating laryngeal mask airway; Position: lateral: Intubation (Tracheal): technique
Sudden loss of airway in patients in the lateral position has always been proven to be difficult to manage with conventional laryngoscopy. We performed a randomized controlled trial to prove the success rate of ventilation and intubation in the lateral position via intubating laryngeal mask airway (ILMA).
Ninety patients were divided into three groups of 30 patients each, positioned supine, right lateral, and left lateral randomly. Each group comprised of both sexes of American Society of Anesthesiologists grade I and II, aged between 18-55 years with normal airway posted for surgery under general anesthesia. Patients were pre-medicated with fentanyl followed by induction with propofol and neuromuscular blockade with rocuronium. ILMA was inserted and blind tracheal intubation via ILMA was done. The success rate, time taken and the number of adjusting maneuvers used for both procedures were recorded. The data was tabulated and analyzed using ANOVA (analysis of variance), multiple 't' test and chi square.
The success rate of intubation (96%) and time taken in insertion and intubation was found to be quite similar in all the three groups.
We conclude that the ILMA has an important role to play in the emergency management of airways in patients in the lateral position in terms of ease, success rate and time taken.
Endotracheal intubation; Fentanyl; Propofol
For patients suspicious of cervical spine injury, a Philadelphia cervical collar is usually applied. Application of Philadelphia cervical collar may cause difficult airway. The aim of this study was to evaluate the laryngeal view and the success rate at first intubation attempt of the Airtraq and conventional laryngoscopy in patients with simulated cervical spine injury after application of a Philadelphia cervical collar.
Anesthesia was induced with propofol, remifentanil, and rocuronium. After a Philadelphia cervical collar applied, patients were randomly assigned to tracheal intubation with an Airtraq (Group A, n = 25) or with conventional laryngoscopy (Group L, n = 25). Measurements included intubation time, success rate of first intubation attempt, number of intubation attempts, and percentage of glottic opening (POGO) score. Mean blood pressure and heart rate were also recorded at baseline, just before and after intubation.
The success rate of the first attempt in Group A (96%) was significantly greater than with the Group L (40%). POGO score was significantly greater in Group A (84 ± 20%) than in Group L (6 ± 11%). The duration of successful intubation at first tracheal intubation attempt and hemodynamic changes were not significantly different between the two groups.
The Airtraq offers a better laryngeal view and higher success rate at first intubation attempt in patients who are applied with a Philadelphia cervical collar due to suspicion of cervical spine injury.
Airtraq; Immobilization; Intubation; Laryngoscopes
Patients with cervical spine instability and limited range of motion are challenge to anesthesiologists. It is important to consider alternatetive methods for securing the airway while maintaining neutral position and minimizing neck motion, because these patients are at increased risk for tracheal intubation failure and neurologic injury during airway management or position change. We experienced two cases that patients had cervical spine instability and severe limited range of motion due to the fusion of the entire cervical spine. One patient was a 6-year-old girl weighing 12.7 kg and had Klippel-Feil syndrome with Arnold-Chiari malformation, the other was a 24-year-old female weighing 31 kg and had juvenile rheumatoid arthritis. We successfully performed the intubation by using the fiberoptic intubation though a laryngeal mask airway in these two cases.
Arnorl-Chiari malformation; Difficult airway; Fiberoptic intubation; Juvenile rheumatoid arthritis; Klippel-Feil syndrome; Laryngeal mask airway
We compared the usefulness of the laryngeal tube (LT) with the intubating laryngeal mask airway (ILMA) in 51 patients whose necks were stabilised by manual in-line traction. After induction of anaesthesia and neuromuscular block, the LT and ILMA were inserted consecutively in a randomised, crossover design. During pressure-controlled ventilation (20 cmH2O inspiratory pressure), we measured insertion attempts, time to establish positive-pressure ventilation, tidal volume, gastric insufflation, and minimum airway pressure at which gas leaked around the cuff. Data were compared using Wilcoxon signed-rank tests; P<0.05 was considered significant. Insertion was more difficult with the LT (successful at first attempt in 16 patients) than with the ILMA (successful at first attempt in 42 patients, P<0.0001). Time required for insertion was longer for the LT (28 [23–35] sec, median [interquartile range]) than the ILMA (20 [15–25] sec, P=0.0009). Tidal volume was less for the LT (440 [290–670] ml) than the ILMA. (630 [440–750] ml, P=0.013). Minimum airway pressure at which gas leak occurred and incidence of gastric insufflation were similar with two devices. In patients whose necks were stabilised with manual in-line traction, insertion of the ILMA was easier and quicker than insertion of the LT and tidal volume was greater with the ILMA than the LT.
Anaesthesia; equipment; airway; intubating laryngeal mask airway; laryngeal tube; cervical spine immobilization
It is difficult to visualise the larynx using conventional laryngoscopy in the presence of cervical spine immobilisation. Airtraq® provides for easy and successful intubation in the neutral neck position.
To evaluate the effectiveness of Airtraq in comparison with the Mc Coy laryngoscope, when performing tracheal intubation in patients with neck immobilisation using hard cervical collar and manual in-line axial cervical spine stabilisation.
A randomised, cross-over, open-labelled study was undertaken in 60 ASA I and II patients aged between 20 and 50 years, belonging to either gender, scheduled to undergo elective surgical procedures. Following induction and adequate muscle relaxation, they were intubated using either of the techniques first, followed by the other. Intubation time and Intubation Difficulty Score (IDS) were noted using Mc Coy laryngoscope and Airtraq. The anaesthesiologist was asked to grade the ease of intubation on a Visual Analogue Scale (VAS) of 1–10. Chi-square test was used for comparison of categorical data between the groups and paired sample t-test for comparison of continuous data. IDS score and VAS were compared using Wilcoxon Signed ranked test.
The mean intubation time was 33.27 sec (13.25) for laryngoscopy and 28.95 sec (18.53) for Airtraq (P=0.32). The median IDS values were 4 (interquartile range (IQR) 1–6) and 0 (IQR 0–1) for laryngoscopy and Airtraq, respectively (P=0.007). The median Cormack Lehane glottic view grade was 3 (IQR 2–4) and 1 (IQR 1–1) for laryngoscopy and Airtraq, respectively (P=0.003). The ease of intubation on VAS was graded as 4 (IQR 3–5) for laryngoscopy and 2 (IQR 2–2) for Airtraq (P=0.033). There were two failures to intubate with the Airtraq.
Airtraq improves the ease of intubation significantly when compared to Mc Coy blade in patients immobilised with cervical collar and manual in-line stabilisation simulating cervical spine injury.
Airtraq®; Mc Coy laryngoscope; immobilization; cervical spine injury
A morbidly obese male who sustained blunt trauma chest with bilateral pneumothorax was referred to the intensive care unit for management of his condition. Problems encountered in managing the patient were gradually increasing hypoxemia (chest trauma with multiple rib fractures with lung contusions) and difficult mask ventilation and intubation (morbid obesity, heavy jaw, short and thick neck). We performed awake endotracheal intubation using an intubating laryngeal mask airway (ILMA) size 4 and provided mechanical ventilation to the patient. This report suggests that ILMA can be very useful in the management of difficult airway outside the operating room and can help in preventing adverse events in an emergency setting.
Blunt trauma chest; intubating laryngeal mask airway; morbid obese
This study investigates the use of dropped neck flexion as a manoeuvre to test the restrictive abilities of two different types of soft collars, an Airway soft cervical collar and a handmade cervical rough. The range of neck flexion of 40 asymptomatic subjects aged 20-29 was assessed, both with and without collar wear, using a Spinal Rangiometer. Dropped neck flexion is described as possibly being more representative of the type of movement that a patient with neck pain will undergo, and hence a more useful manoeuvre to employ when testing for the restrictive abilities of soft cervical collars. The mean dropped flexion was 64 degrees without collar wear, 58 degrees with the Airway soft collar, and 34 degrees with the cervical rough. Only the cervical rough provided both statistically (p < 0.001) and clinically (> 15°) significant restriction of dropped neck flexion. The comfort, preparation time, and ease of application of each of these collars is not addressed in this study, and may reflect on use in clinical practice. This preliminary study provides insight and pilot data for future studies in this area.
neck; collars; range of motion; whiplash injuries; chiropractic; manipulation
The ProSeal laryngeal mask airway (PLMA) is a unique laryngeal mask with a modified cuff to improve seal and a channel to facilitate gastric tube placement. This is a better device in difficult airway situations compared to classic laryngeal mask airway. This prompted us to study the ease of insertion and positioning of PLMA in patients with simulated restricted neck mobility while using gum elastic bougie (GEB) group or introducer tool (group IT) to aid insertion.
Sixty ASA I or II patients, aged between 18 years and 60 years, undergoing minor non-head and neck surgeries in the supine position were studied. A rigid neck collar was used to simulate restricted neck mobility in all patients. After anaesthetising the patients with a standard protocol, the PLMA was inserted using either of the technique using the tongue depressor to open the mouth. The ease of insertion, positioning, haemodynamic responses to insertion and other complications related to the procedure were noted.
Regarding demographic variables, both groups were similar. The mean time taken for insertion of PLMA in group GEB was 67.80 s as compared to 46.79 s in group IT (P<0.05). Patients of group GEB had better positioning assessed by an intubating fiberscope with less end tidal carbon-di-oxide (ETCO2) values. Systolic and diastolic blood pressures were similar. The incidence of sore throat, dysphagia, and dysphonia were higher in IT group in the 12 h, but similar in 24 h.
Guided insertion technique with GEB took a longer time, but had a better positioning and lower ETCO2 values when compared to IT technique.
Difficult airway; gum elastic bougie; ProSeal laryngeal mask; simulation
To compare the ability of UK paramedics to intubate a simulated difficult airway using a Mackintosh laryngoscope versus an intubating laryngeal mask airway (ILMA).
A randomised controlled trial.
100% of the paramedics were able to intubate a simulated difficult airway using the ILMA versus 0% of those using the Mackintosh laryngoscope.
This study has demonstrated the ability of paramedics to use the ILMA when faced with a difficult intubation. However, further evaluation of this potential role for the ILMA is required.
The cervical spine has to be stabilized in patients with suspected cervical spine injury during laryngoscopy and intubation by manual in-line axial stabilization. This has the propensity to increase the difficulty of intubation. An attempt has been made to compare TruView EVO2 and McCoy with cervical spine immobilization, which will aid the clinician in choosing an appropriate device for securing the airway with an endotracheal tube (ETT) in the clinical scenario of trauma.
To compare the effectiveness of TruView EVO2 and McCoy laryngoscopes when performing tracheal intubation in patients with neck immobilization using manual in-line axial cervical spine stabilization.
Settings and design:
K. M. C. Hospital, Mangalore, This was a randomized control clinical trial.
Sixty adult patients of either sex of ASA physical status 1 and 2 who were scheduled to undergo general anesthesia with endotracheal intubation were studied. Comparison of intubation difficulty score (IDS), hemodynamic response, Cormack and Lehane grade, duration of the tracheal intubation and rate of successful placement of the ETT in the trachea between TruView EVO2 and McCoy laryngoscopes was performed.
The results demonstrated that TruView has a statistically significant less IDS of 0.33 compared with an IDS of 1.2 for McCoy. TruView also had a better Cormack and Lehane glottic view (CL 1 of 77% versus 40%) and less hemodynamic response.
The TruView blade is a useful option for tracheal intubation in patients with suspected cervical spine injury.
Cervical spine injury; manual in-line axial stabilization; McCoy laryngoscopes; tracheal intubation; TruView EVO2
We compared hemodynamic responses and upper airway morbidity following tracheal intubation via conventional laryngoscopy or intubating laryngeal mask airway in hypertensive patients.
Forty-two hypertensive patients received a conventional laryngoscopy or were intubated with a intubating laryngeal mask airway. Anesthesia was induced with propofol, fentanyl, and cis-atracurium. Measurements of systolic and diastolic blood pressures, heart rate, rate pressure product, and ST segment changes were made at baseline, preintubation, and every minute for the first 5 min following intubation. The number of intubation attempts, the duration of intubation, and airway complications were recorded.
The intubation time was shorter in the conventional laryngoscopy group than in the intubating laryngeal mask airway group (16.33±10.8 vs. 43.04±19.8 s, respectively) (p<0.001). The systolic and diastolic blood pressures in the intubating laryngeal mask airway group were higher than those in the conventional laryngoscopy group at 1 and 2 min following intubation (p<0.05). The rate pressure product values (heart rate x systolic blood pressure) at 1 and 2 min following intubation in the intubating laryngeal mask airway group (15970.90±3750 and 13936.76±2729, respectively) were higher than those in the conventional laryngoscopy group (13237.61±3413 and 11937.52±3160, respectively) (p<0.05). There were no differences in ST depression or elevation between the groups. The maximum ST changes compared with baseline values were not significant between the groups (conventional laryngoscopy group: 0.328 mm versus intubating laryngeal mask airway group: 0.357 mm; p = 0.754). The number and type of airway complications were similar between the groups.
The intense and repeated oropharyngeal and tracheal stimulation resulting from intubating laryngeal mask airway induces greater pressor responses than does stimulation resulting from conventional laryngoscopy in hypertensive patients. As ST changes and upper airway morbidity are similar between the two techniques, conventional laryngoscopy, which is rapid and safe to perform, may be preferred in hypertensive patients with normal airways.
Intubating laryngeal mask airway; Conventional laryngoscopy; Hemodynamic responses; Airway morbidity; Hypertensive patients
The Truview EVO2™ laryngoscope is a recently introduced device with a unique blade that provides a magnified laryngeal view at 42° anterior reflected view. It facilitates visualization of the glottis without alignment of oral, pharyngeal, and tracheal axes. We compared the view obtained at laryngoscopy, intubating conditions and hemodynamic parameters of Truview with Macintosh blade.
Materials and Methods:
In prospective, randomized and controlled manner, 200 patients of ASA I and II of either sex (20–50 years), presenting for surgery requiring tracheal intubation, were assigned to undergo intubation using a Truview or Macintosh laryngoscope. Visualization of the vocal cord, ease of intubation, time taken for intubation, number of attempts, and hemodynamic parameters were evaluated.
Truview provided better results for the laryngeal view using Cormack and Lehane grading, particularly in patients with higher airway Mallampati grading (P < 0.05). The time taken for intubation (33.06±5.6 vs. 23.11±57 seconds) was more with Truview than with Macintosh blade (P < 0.01). The Percentage of Glottic Opening (POGO) score was significantly higher (97.26±8) in Truview as that observed with Macintosh blade (83.70±21.5). Hemodynamic parameters increased after tracheal intubation from pre-intubation value (P < 0.05) in both the groups, but they were comparable amongst the groups. No postoperative adverse events were noted.
Tracheal intubation using Truview blade provided consistently improved laryngeal view as compared to Macintosh blade without the need to align the oral, pharyngeal and tracheal axes, with equal attempts for successful intubation and similar changes in hemodynamics. However, the time taken for intubation was more with Truview.
Airway; difficult intubation; equipment; Macintosh laryngoscope; tracheal intubation; Truview EVO2 laryngoscope
The Aintree intubating catheter (Cook® Medical Inc., Bloomington, IN, USA) has been shown to successfully facilitate difficult intubations when other methods have failed. The Aintree intubating catheter (Cook® Medical Inc., Bloomington, IN, USA) has a fixed length of 56 cm, and it has been suggested in the literature that it may be too short for safe use in patients who are tall.
We present the case of a 32-year-old, 180 cm tall Caucasian woman with a predicted difficult airway who presented to our facility for an emergency cesarean section. After several failed intubation attempts via direct laryngoscopy, an airway was established with a laryngeal mask airway. After delivery of a healthy baby, our patient's condition necessitated tracheal intubation. A fiber-optic bronchoscope loaded with an Aintree intubating catheter (Cook® Medical Inc., Bloomington, IN, USA) was passed through the laryngeal mask airway into the trachea until just above the carina, but was too short to safely allow for the passage of an endotracheal tube.
We present a novel technique in which the Aintree intubating catheter (Cook® Medical Inc., Bloomington, IN, USA) was replaced with a longer (100 cm) exchange catheter, over which an endotracheal tube was passed successfully into the trachea.
Supraglottic airway devices have been used as an alternative to tracheal intubation during laparoscopic surgery.
The study was designed to compare the efficacy of Streamlined Liner of the Pharynx Airway (SLIPA) for positive pressure ventilation and postoperative complications with the Laryngeal Mask Airway ProSeal (PLMA) for patients undergoing lower abdominal laparoscopies under general anesthesia with controlled ventilation.
Settings and Design:
Prospective, crossover randomized controlled trial performed on patients undergoing lower abdominal laparoscopic surgeries.
A total of 120 patients undergoing lower abdominal laparoscopic surgeries were randomly allocated into two equal groups; PLMA and SLIPA groups. Number of intubation attempts, insertion time, ease of insertion, and fiberoptic bronchoscopic view were recorded. Lung mechanics data were collected 5 minutes after securing the airway, then after abdominal insufflation. Blood traces and regurgitation were checked for; postoperative sore throat and other complications were recorded.
Arithmetic mean and standard deviation values were calculated and statistical analyses were performed for each group. Independent sample t-test was used to compare continuous variables exhibiting normal distribution, and Chi-squared test for noncontinuous variables. P value <0.05 was considered significant.
Insertion time, first insertion success rate, and ease of insertion were comparable in both groups. Fiberoptic bronchoscopic view was significantly better and epiglottic downfolding was significantly lower in SLIPA group. Sealing pressure and lung mechanics were similar. Gastric distension was not observed in both groups. Postoperative sore throat was significantly higher in PACU in PLMA group. Blood traces on the device were significantly more in SLIPA group.
SLIPA can be used as a useful alternative to PLMA in patients undergoing lower abdominal laparoscopic surgery with muscle relaxant and controlled ventilation.
Laparoscopic surgery; proseal lma; streamlined liner of the pharynx airway; supraglottic airway devices
Out-of-hospital endotracheal intubation performed by paramedics using the Macintosh blade for direct laryngoscopy is associated with a high incidence of complications. The novel technique of video laryngoscopy has been shown to improve glottic view and intubation success in the operating room. The aim of this study was to compare glottic view, time of intubation and success rate of the McGrath® Series 5 and GlideScope® Ranger video laryngoscopes with the Macintosh laryngoscope by paramedics.
Thirty paramedics performed six intubations in a randomised order with all three laryngoscopes in an airway simulator with a normal airway. Subsequently, every participant performed one intubation attempt with each device in the same manikin with simulated cervical spine rigidity using a cervical collar. Glottic view, time until visualisation of the glottis and time until first ventilation were evaluated.
Time until first ventilation was equivalent after three intubations in the first scenario. In the scenario with decreased cervical motion, the time until first ventilation was longer using the McGrath® compared to the GlideScope® and AMacintosh (p < 0.01). The success rate for endotracheal intubation was similar for all three devices. Glottic view was only improved using the McGrath® device (p < 0.001) compared to using the Macintosh blade.
The learning curve for video laryngoscopy in paramedics was steep in this study. However, these data do not support prehospital use of the McGrath® and GlideScope® devices by paramedics.
We report the perioperative course of a patient with long standing ankylosing spondylitis with severe dysphagia due to large anterior cervical syndesmophytes at the level of the epiglottis. He was scheduled to undergo anterior cervical decompression and the surgical approach possibly precluded an elective pre-operative tracheostomy. We performed a modified awake fibreoptic nasal intubation through a split nasopharyngeal airway while adequate oxygenation was ensured through a modified nasal trumpet inserted in the other nares. We discuss the role of nasal intubations and the use of both the modified nasopharyngeal airways we used to facilitate tracheal intubation. This modified nasal fibreoptic intubation technique could find the application in other patients with cervical spine abnormalities and in other anticipated difficult airways.
Airways; airways - difficult anticipated; co-existing diseases - ankylosing spondylitis; diffuse idiopathic skeletal hyperostosis; fiberoptic; intubation; intubation - awake; modified nasal trumpet; nasal; nasal - airway; split nasopharyngeal airway
Paramedics are frequently required to perform tracheal intubation, a potentially life-saving manoeuvre in severely ill patients, in the prehospital setting. However, direct laryngoscopy is often more difficult in this environment, and failed tracheal intubation constitutes an important cause of morbidity. Novel indirect laryngoscopes, such as the Airtraq® and Truview® laryngoscopes may reduce this risk.
We compared the efficacy of these devices to the Macintosh laryngoscope when used by 21 Paramedics proficient in direct laryngoscopy, in a randomized, controlled, manikin study. Following brief didactic instruction with the Airtraq® and Truview® laryngoscopes, each participant took turns performing laryngoscopy and intubation with each device, in an easy intubation scenario and following placement of a hard cervical collar, in a SimMan® manikin.
The Airtraq® reduced the number of optimization manoeuvres and reduced the potential for dental trauma when compared to the Macintosh, in both the normal and simulated difficult intubation scenarios. In contrast, the Truview® increased the duration of intubation attempts, and required a greater number of optimization manoeuvres, compared to both the Macintosh and Airtraq® devices.
The Airtraq® laryngoscope performed more favourably than the Macintosh and Truview® devices when used by Paramedics in this manikin study. Further studies are required to extend these findings to the clinical setting.
The Glidescope Videolaryngoscope (GVL) is a newly developed video laryngoscope. It offers a significantly improved laryngeal view and facilitates endotracheal intubation in difficult airways, but it is controversial in that it offers an improved laryngeal view in normal airways as well. And the price of GVL is expensive. We hypothesized that intubation carried out by fully experienced anesthesiologists using the GVL with appropriate pre-anesthetic preparations offers an improved laryngeal view and shortened intubation time in normal airways. Therefore, the aim of this study was to compare the GVL with the Macintosh laryngoscope in normal airways and to determine whether GVL can substitute the Macintosh laryngoscope.
This study included 60 patients with an ASA physical status of class 1 or 2 requiring tracheal intubation for elective surgery. All patients were randomly allocated into two groups, GVL (group G) or Macintosh (group M). ADS (airway difficulty score) was recorded before induction of anesthesia. The anesthesiologist scored vocal cord visualization using the percentage of glottic opening (POGO) visible and the subjective ease of intubation on a visual analogue scale (VAS). The time required to intubate was recorded by an assistant.
There was a significant increase in POGO when using the GVL (P < 0.05). However, there was no difference in the time required for a successful tracheal intubation using the GVL compared with the Macintosh laryngoscope. The VAS score on the ease of intubation was significantly lower for the GVL than for the Macintosh laryngoscope (P < 0.05).
GVL could be a first-line tool in normal airways.
Glidescope; Intubation; Macintosh laryngoscope
Extracranial involvement of the recurrent laryngeal nerve and the hypoglossal nerve is known as Tapia’s syndrome. Ipsilateral paralysis of the vocal cord and tongue is present. Lesion of these nerves may be a rare complication of airway management. Herein, a case of Tapia’s Syndrome complicating transoral intubation during general anaesthesia in a rhinoplasty operation, together with a review of pertinent literature to evaluate the incidence and the possible pathogenic mechanism of the lesion.
There are recent reports in the literature on mono or bilateral paralysis of the XII or laryngeal recurrent nerve after use of laryngeal mask with a pathogenic mechanism of compression. Furthermore, there are reports, following oro-tracheal intubation, of recurrent laryngeal paralysis, likely legacies to the compression of the anterior branch of inferior laryngeal nerve by the cuff of the oro-tracheal tube against the postero-medial part of the thyroid cartilage. Hypoglossal nerve damage could be caused by a stretching of the nerve against the greater horn of the hyoid bone by a laryngeal mask or oro-tracheal tube or compression of the posterior part of the laryngoscope or oro-tracheal tube. In our case, the lesion probably occurred as the result of a two-fold compressive mechanism: on one hand, compression by the cuff of the endo-tracheal tube due to excessive throat pack in the oro-pharynx; on the other hand a prolonged stretching mechanism of these nerves may have occurred due to excessive anterior and lateral flexion of the head.
From the data reported in the literature, as in our case, complete recovery of function is generally achieved within the first six months. This progressive recovery of function suggests nerve damage of a neuro-praxic type, which is typical of compression injury.
In conclusion, the response of this rare complication confirms the importance not only of the position of the head and patient on the operating table but also the meticulous and correct performance of the routine manoeuvres of airway management.
Nasal surgery; Complications; Cranial nerve paralysis; Tapia’s syndrome
We report the case of a 30 year old man managed in an out of hospital setting for a cardiorespiratory arrest. The patient was impossible to intubate under direct laryngoscopy because of a severe mouth opening limitation associated with a buffalo neck. After failure of direct laryngoscopy and intubating laryngeal mask airway, an Eschmann tracheal tube introducer (gum elastic bougie) was introduced through a nostril. The bougie could be blindly inserted into the trachea, and the patient was intubated using the bougie as a guide. Tracheal intubation was then confirmed using the syringe aspiration test and end tidal carbon dioxide detection.
out of hospital; cardiopulmonary resuscitation; airway management; difficult intubation
Tracheal Intubation is an important yet difficult skill to learn with many possible methods and techniques. Direct laryngoscopy is the standard method of tracheal intubation, but several instruments have been shown to be less difficult and have better performance characteristics than the traditional direct method. We compared 4 different intubation methods performed by novice intubators on manikins: conventional direct laryngoscopy, video laryngoscopy, Airtraq® laryngoscopy, and fiberoptic laryngoscopy. In addition, we attempted to find a correlation between playing videogames and intubation times in novice intubators. Video laryngoscopy had the best results for both our normal and difficult airway (cervical spine immobilization) manikin scenarios. When video was compared to direct in the normal airway scenario, it had a significantly higher success rate (100% vs 83% P=.02) and shorter intubation times (29.1±27.4 sec vs 45.9±39.5 sec, P=.03). In the difficult airway scenario video laryngoscopy maintained a significantly higher success rate (91% vs 71% P=0.04) and likelihood of success (3.2±1.0 95%CI [2.9–3.5] vs 2.4±0.9 95%CI [2.1–2.7]) when compared to direct laryngoscopy. Participants also reported significantly higher rates of self-confidence (3.5±0.6 95%CI [3.3–3.7]) and ease of use (1.5±0.7 95%CI [1.3–1.8]) with video laryngoscopy compared to all other methods. We found no correlation between videogame playing and intubation methods.
A prone position is not a standard position for anesthesia induction and associated with problems like difficult mask fit, impairment of orotracheal intubation by direct laryngoscopy, and reduction of pulmonary compliance. However anesthetic management of trauma victims presenting with penetrating posterior lumbar spine injury requires airway securement and induction of anesthesia in the prone position to avoid further neurological impairment. We herein present the first reported case of an adult trauma patient presented with an impaled knife protruding out of lower back, who underwent endotracheal intubation with an intubating laryngeal mask airway under general anesthesia in the prone position. Our experience indicates that this technique would be easier and less risky compared to direct laryngoscopy or awake fiber optic intubation and might be considered in an emergency situation.
Airway management; endotracheal intubation; intubating laryngeal mask airway; prone position