Airway Scenarios Research Articles

Abstract No.: ABS2053: Comparision of ease of tracheal intubation using video stylet and c-mac videolaryngoscope in difficult airway scenario : a randomised controlled trial

Background & Aims:Managing difficult airway is challenging and over the years many devices have been utilised to overcome the issue. The aim of thisstudy was to evaluate the efficacy of Video-stylet in difficult airway scenario compared with C-Mac Videolaryngoscopeon adult patients.Methods:A Prospective randomised controlled trial was conducted in 60 adult patients of American Society of Anesthesiologists (ASA) I and II posted for elective surgeries under general anaesthesia at JNMC Belagavi. They were randomised equally into group C-mac and group video-stylet (VS) with cervical collar applied before induction.Patients undergoing emergency surgery, those requiring rapid-sequence intubation were excluded. Sample size calculated using G *3.1:1 tests for co-relation and regression analysis. Ethical clearance was obtained. PAE and airway difficulty were assessed pre-operatively, cervical collar was applied before premedication, induced with Propofol (2 mg/kg) and scoline (2 mg/kg). ADS, Time taken for intubation, successrate, POGO score, IDS were parametersobserved.Continuous variables expressed in median and analysed using Mann-Whitney test and categorical variable with Chi square test.Results:Gender distribution,age(Mean-Group C-Mac 38.03 years,group VS 39.43 years), BMI (group C-Mac-22.8, group VS-23.48 kg/m2) were comparable in the two groups. ADS (group C-Mac-7.93, group VS-7.47) was comparable. The mean time for intubation in Group C-Mac was 25.07 seconds and in Group VS was 22.07 seconds. 8 patients required second attempt for successful intubation in group C-Mac compared to 3 in VS group, the difference was not statistically significant (P=0.2). IDS between the two groups suggested statistically superior results with VS group than C-mac group.POGO was significantly lower with C-mac group.Table 1Gender distribution of the patients in the studyGroup C-MacGroup VS No%No.%Gender Male12401653.3 Female18601446.7 Total3010030100 Conclusion:The Video-stylet demonstrated comparable first-attempt success rate for intubation and shorter intubation time than the C-mac videolaryngoscope in difficult airway scenario.These results suggest that the video-stylet may be a better option fortracheal intubation in difficult airway scenario.

EVALUATION OF SKILL ACQUISITION OF VIDEOLARYNGOSCOPY IN COMPARISON TO DIRECT LARYNGOSCOPY IN POSTGRADUATE MEDICAL STUDENTS: A MANIKIN STUDY

Background: Direct laryngoscopy with Macintosh laryngoscope (ML) is the gold standard technique for tracheal intubation. However, visualization of the larynx and subsequent tracheal intubation may not be possible in difcult airways. TruView video laryngoscope (TVL) can provide good visualization of the glottis and visual conrmation of tracheal intubation in a difcult airway scenario. This manikin study was carried out to compare the skill acquisition for videolaryngoscopy using TVL and compare it with direct laryngoscopy using ML, in easy and difcult airway scenarios, in TVL novice participants. Material and methods: Thirty resident doctors were randomized to participate in a crossover, manikin study. Participants were asked to intubate a manikin in easy and difcult airway scenarios using TruView and Macintosh laryngoscope. Two trials were conducted at one-week interval and at the end of each trial parameters of Intubation time, Cormack-Lehane (CL) grading, success of intubation and ease of intubation which reect skill acquisition were recorded. All 30 participants completed the study. Results: In the easy scenario most results were comparable between the two devices. The TVL scored over ML in all aspects of difcult intubation with signicantly lesser time for intubation (23.27 ± 1.8sec, P<0.0001), lower CL grade (1&2-100%), higher success of intubation in the rst attempt (83.33%, P=0.0016) and greater ease of intubation (100%, P<0.0001). Conclusion: TVL scores over ML in difcult airway scenarios in novice users of TVL, within a short learning time.

Anesthetic management in a child with Coffin Siris syndrome.

Dear Editor, An 8-year-old boy with ARID1B-CSS Coffin Siris Syndrome (CSS) presented with left inguinal hernia for herniotomy. The child had an uneventful neonatal period but developed recurrent upper respiratory tract infection at 2 months of age requiring frequent hospitalization. He also developed an intellectual disability, hyperactivity, and seizure disorder. Evaluated as a floppy infant, genetic workup revealed ARID1B and SOX11 gene mutation associated with CSS. He had a hypoplastic fifth finger in his hands, bushy eyebrows, everted lips, coarse facies, hypertrichosis, hypotonia, micrognathia, macroglossia, and high arched palate [Figure 1].Figure 1: (a) Note bushy eyebrows, coarse facies, hypertrichosis, everted lips, macroglossia, low anterior hairline, prominent ears (b) Hypoplastic fifth finger (c) Airway secured with Size 2 i-GelOn examination, the child was anxious, aggressive, and distracted. He was premedicated with oral midazolam 30 min prior and induced with sevoflurane. After achieving end-tidal concentration of 2.5%, iv cannula was placed and airway secured with size-2 i-Gel. The patient was maintained with sevoflurane at MAC 1-1.2 and pressure support ventilation (PSV-Pro, GE Datex Ohmeda, Aspire View). No opioids or muscle relaxant was used. Ultrasound-guided ilioinguinal and iliohypogastric nerve block (IIN/IHN) was given. At the end of the surgery, i-Gel was removed deep after ascertaining adequacy of ventilation. The patient was observed for 24 h before discharge. CSS (OMIM 135900), first described by Coffin GS, is a rare genetic condition caused by mutations in the ARID1B gene with a prevalence of <1:100000 and equal male-female preponderance.[1,2] Known as “fifth digit syndrome,” CSS is characterized by moderate to severe intellectual disability, absent or hypoplastic terminal phalanx of the fifth digit, craniofacial abnormalities, coarse facies, hypertrichosis, hypotonia, short neck, irregular and protruding teeth, wide nose with low nasal bridge, macroglossia, micrognathia, and high arched palate.[2] These features lead to feeding difficulties, recurrent respiratory tract infections during infancy owing to micro-aspirations, and pose a risk of transient apnea/laryngospasm in the perioperative period. Combined with facial dysmorphism, these factors present a difficult airway scenario. Awake flexible fiber-optic intubation is the best approach but possible in compliant patients only. In our case, the child was uncooperative and aggressive due to mental retardation, and the surgery did not necessitate tracheal intubation. Therefore, we used supra-glottic airway (i-Gel) while preserving spontaneous respiration. Numerous case reports have described the genotypic and phenotypic profile of CSS; however, few have described anesthetic management of patients with CSS, the details of which are mentioned in Table 1.[3–5] Spinal abnormalities such as spina bifida, scoliosis, etc., have been associated with CSS. Although no such abnormalities were found in our patient, we did not contemplate neuraxial block in our patient as IIN/IHN has proven to be equal or more efficacious and safer than caudal/central neuraxial block. Moreover, opioid-free anesthesia led to a faster and smoother recovery.Table 1: Airway management Techniques reported in patients with CSSCSS is a rare congenital syndrome with distinct craniofacial anomalies and mental retardation presenting a challenging scenario to the anesthesiologist in the perioperative period. Detailed insight of the child’s condition, thorough preoperative workup, and difficult airway preparedness are essential. Supra-glottic airway device presents an important tool in the armamentarium of anesthesiologist and a viable and easy alternative to flexible fiber-optic intubation for successful management of such cases. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Retromolar intubation with video intubating stylet in difficult airway: A randomized crossover manikin study

ObjectiveDifficult airway situations, such as trismus and neck rigidity, may prohibit standard midline orotracheal intubation. An alternative route of intubation from the retromolar space using a fiberoptic scope or rigid intubation stylet has been reported. There is no study investigating the applicability of retromolar intubation using a video intubating stylet. This study comparatively analyzed difficult airway management using a video intubating stylet in the retromolar and standard midline approaches. MethodsA randomized crossover manikin study was conducted between January 2021 and June 2021 at a tertiary teaching hospital. Thirty-six emergency medicine residents and attending physicians were enrolled, and all participated in an educational course regarding video intubating stylet in standard midline and retromolar approaches. Then, they performed both intubation approaches in a randomized order on a manikin seven times with different airway settings each time. The duration of successful intubation, first attempt success rate, overall success rate, number of attempts, and self-reported difficulty were recorded and compared. ResultsThirty-six emergency physicians were included in the study. Compared with the standard midline approach, the use of the retromolar approach significantly reduced the duration of successful intubation in difficult airway scenarios such as limited mouth opening and neck rigidity with (44.77 [28.58–63.65] vs. 120 [93.86–120] s, p < 0.001) and without tongue edema (31.5 [22.57–57.74] vs. 44.72 [36.23–65.34] s, p = 0.012). Furthermore, the retromolar approach increased the first attempt success rate in scenarios of limited mouth opening and neck rigidity with (91.67% vs. 16.67%, p < 0.001) and without (97.22% vs. 72.22%, p = 0.012) tongue edema. The self-reported difficulty was also significantly lower with the retromolar approach than with the standard approach in the above two scenarios. ConclusionsThe retromolar approach for intubation using a video intubating stylet may be a promising choice for selected patients with a combination of difficult airway features such as limited mouth opening, neck rigidity, and edematous tongue.

Assessment of the GlideScope spectrum single-use video laryngoscope blades and small GlideRite stylet for use in pediatrics: A randomized manikin study

The GlideScope® Spectrum™ single use blades, LoPro S1 and LoPro S2, offer several technical improvements over their predecessors while maintaining the traditional curvature useful in difficult airway scenarios. We performed a single-site, prospective randomized feasibility study with three different pediatric manikin models using these new blades. The primary outcome was first attempt success rate. Secondary outcomes were overall success rate, time to intubation, and Cormack and Lehane glottic view grade. A questionnaire was also administered to each participant following the intubation attempts to gauge their satisfaction with the Spectrum™ blades and proprietary stylet. Fifty total anesthesia providers consisting of attendings (consultants), residents, fellows, certified nurse anesthetists and certified anesthesiologist assistants intubated 3 different manikins, three times each, using both the LoPro S1 and LoPro S2 blades for a total of 18 intubations each. The overall success rate across all blades and manikins was 98% and greater. The median time to intubation for all blade and manikin combinations was less than 13 s. This study demonstrates the GlideScope® Spectrum™ LoPro S1 and LoPro S2 blades are effective video intubation devices, even in a difficult airway pediatric manikin model.

Airway consideration in cleft patients-challenges and approaches

Over the last few decades, there is a paramount shift in the implementation of pediatric anesthesia. Although for most of the time, difficult airway scenarios are well-planned and executed, occasionally an unanticipated difficult situation may still arise. This is more common in patients with orofacial anomalies such as cleft lip and palate which constitute one of the most common craniofacial anomalies. Various approaches to difficult airway management in an infant undergoing cleft repair have been described in the literature. However, no approach is considered ideal. It depends on age, associated anomalies, at hand resources, and the skill of the anesthesiologist. The unique anatomical and physiological features of pediatric airways impose additional challenges. The evolution of advanced airway modalities such as video laryngoscopes (VLs) and fiber-optic bronchoscopes had a major impact on the practice of anesthesia and the management of difficult airway scenarios in children and neonates. This article focuses on airway assessment and various current techniques and equipment used in airway management of cleft anomalies. Pediatric airway devices such as supraglottic airways, VLs, and fiber-optic bronchoscopes are briefly discussed with the benefits and limitations of each device. Recent studies describe specific problems as well as advantages with the usage of these devices.

Difficult Airway ManagementA Challenge to Anaesthesiologists

Anticipated and unanticipated difficult airway remains an everlasting challenge for anesthesiologist. Most airway problems can be solved with enough resources available but clinical judgment borne of experience, and expertise is crucial in implementing the skills in any difficult airway scenario. Detailed patient history, best utilisation patient protocols, with good clinical assessment may reduce the difficult airway complications. The present series reports six patients with anticipated difficult airway-burn contracture, fractured mandible with restricted mouth opening: meningo myelocoele (in a neonate, and there was difficulty in positioning for intubation), anterior mediastinal mass (with difficulty in maintenance of anesthesia), cervical spine injury and one patient with left mandible fracture with history of road traffic accident. Different methods were successfully adopted for managing all of these difficult airway cases. Hence planning, preparation, and execution is very important in successful management of difficult airway.

Role of conferences and continuing medical education (CME) in post-graduate anaesthesia education.

Role of conferences and continuing medical education (CME) in post-graduate anaesthesia education.

Share the Airway: An Interdisciplinary Course for Management of the Unexpected Difficult Airway

IntroductionWithin the scope of practice of oral and maxillofacial surgery, the unexpected difficult airway may occur in the trauma bay, operating theater, postoperative, or office-based setting. Oral and maxillofacial surgeons must be trained to diagnose and intervene in anatomically or anesthetically compromised airways. An interdisciplinary training course hosted by an anesthesiology airway expert and oral and maxillofacial surgeon is a novel resident training opportunity. Materials and methodsIn August 2019 and October 2020, the department of anesthesiology and the division of oral and maxillofacial surgery at Weill Cornell Medical College/NewYork-Presbyterian Hospital, New York, NY, co-hosted interdisciplinary educational sessions focused on management of the unexpected difficult airway, taught to residents and faculty. A SurveyMonkey (San Mateo, CA) questionnaire was taken 2 weeks before and after the course, with 10 questions assessing fund of knowledge in airway anatomy and physiology, etiology of difficult airway scenarios, difficult airway algorithm, and performance of emergency surgical airways. An interactive lecture on likely scenarios, airway algorithms, relevant surgical anatomy, routine and emergency airway management, airway devices, and emergency surgical airway techniques was conducted. A hands-on cricothyroidotomy tutorial using Crico-Trainer “Pig” (VBM, Sulz, DE) anatomic models with fresh porcine tracheas to simulate human airway anatomy were used. A post-course test consisted of a timed, filmed performance followed by a debriefing session. ResultsIncreased fund of knowledge and comfort with airway anatomy, difficult airway diagnosis and management, and emergency surgical airway techniques was evident between pre-and post-course surveys and was clearly demonstrated across multiple years. The sample size (n = 10, 2019; n = 7, 2020) was insufficient for statistical analysis. ConclusionInterdisciplinary didactic and clinical training in emergency airway management are of paramount importance to the oral and maxillofacial surgeon. Between years, a drop-off in knowledge base and technical skills occurred, even among senior staff, and all attendees agreed that periodic repetition is worthwhile. This course is now offered as part of the core curriculum on an annual basis and may be expanded to additional specialties for whom airway management is important.

Newer Airway Gadgets: Rescuers in Difficult Airway Scenarios

Background: As anaesthetists, we may constantly be in the learning curve of the management of difficult airway scenario. It can have a disastrous outcome if one is not adequately prepared with the right equipment. Over time there has been multiple ways to tackle difficult airway scenarios. Needless to say, appropriate airway gadgets are carefully chosen according to the surgery and patient characteristics. But what if these certain techniques fail? Then, what next? The inability to efficiently manage a difficult airway is the major cause of morbidity and mortality in anaesthetic practice. Here, we discuss 4 different case scenarios of difficult airway management. case reports:Case 1 was a pediatric patient with TMJ ankylosis, with mouth opening 4mm, in whom we used the fibreoptic technique. Case 2- A failed fibreoptic attempt in a case of recurrent Ca oral cavity where we secured the airway using Airtraq videolaryngoscope. Case 3- A patient with post burn contracture over front of neck and anterior shoulder where we decided to use intubating laryngeal mask airway for securing airway and Case 4- An obese female patient posted for hysterolaparoscopy where we used the Laryngeal Mask Airway Supreme. Conclusion: Effective usage of newer drugs, equipment and airway gadgets by technically skilled personnel, with sound clinical judgement are essential factors in reducing airway related adverse scenario and it is of utmost importance to keep these alternate gadgets handy and to be proficient with its usage.

Comparison of the novel VieScope with conventional and video laryngoscope in a difficult airway scenario \u2013 a randomized, controlled simulation trial

BackgroundEndotracheal intubation continues to be the gold standard for securing the airway in emergency situations. Difficult intubation is still a dreadful situation when securing the airway.ObjectiveTo compare VieScope with Glidescope and conventional Macintosh laryngoscopy (MAC) in a simulated difficult airway situation.MethodsIn this randomized controlled simulation trial, 35 anesthesiologists performed endotracheal intubation using VieScope, GlideScope and MAC in a randomized order on a certified airway manikin with difficult airway.ResultsFor the primary endpoint of correct tube position, no statistical difference was found (p = 0.137). Time until intubation for GlideScope (27.5 ± 20.3 s) and MAC (20.8 ± 8.1 s) were shorter compared to the VieScope (36.3 ± 10.1 s). Time to first ventilation, GlideScope (39.3 ± 21.6 s) and MAC (31.9 ± 9.5 s) were also shorter compared to the VieScope (46.5 ± 12.4 s). There was no difference shown between handling time for VieScope (20.7 ± 7.0 s) and time until intubation with GlideScope or MAC. Participants stated a better Cormack & Lehane Score with VieScope, compared to direct laryngoscopy.ConclusionRate of correct tracheal tube position was comparable between the three devices. Time to intubation and ventilation were shorter with MAC and Glidescope compared to VieScope. It did however show a comparable handling time to video laryngoscopy and MAC. It also did show a better visualization of the airway in the Cormack & Lehane Score compared to MAC.Trial registrationThe study was registered at the German Clinical Trials Register www.drks.de (Identifier: DRKS00024968) on March 31st 2021.

Pre-tracheotomy for Potentially Emergent Airway Scenarios: Indications and Outcomes.

Airway access in the setting of unsuccessful ventilation and intubation typically involves emergent cricothyrotomy or tracheotomy, procedures with associated significant risk. The potential for such emergent scenarios can often be predicted based on patient and disease factors. Planned tracheotomy can be performed in these cases but is not without its own risks. We previously described a technique of pre-tracheotomy or exposing the tracheal framework without entering the trachea, as an alternative to planned tracheostomy in such cases. In this way, a tracheotomy can be easily completed if needed, or the wound can be closed if it is not needed. This procedure has since been used in an array of indications. We describe the clinical situations where pre-tracheotomy was performed as well as subsequent patient outcomes. Retrospective series of patients undergoing a pre-tracheotomy from 2015 to 2020. Records were reviewed for patient characteristics, indication, whether the procedure was converted to tracheotomy or closed at the bedside, and any post-procedural complications. Pre-tracheotomy was performed in 18 patients. Indications included failed extubation after head and neck reconstruction, subglottic stenosis, laryngeal masses, laryngeal edema, thyroid masses, and an oropharyngeal bleed requiring operative intervention. Tracheotomy was avoided in 10 patients with wound closed at the bedside; procedure was converted to tracheotomy in the remaining eight. There were no complications. Indications for conversion included failed extubation, intraoperative hemorrhage, significant stridor with dyspnea, and inability to ventilate. Pre-tracheotomy offers simplified airway access and provides a valuable option in scenarios where tracheotomy may, but not necessarily, be needed. 4 Laryngoscope, 131:E2802-E2809, 2021.

Comparison of learning direct laryngoscopy using a McGrath videolaryngoscope as a direct versus indirect laryngoscope: a randomized controlled trial.

ObjectiveTracheal intubation using a direct laryngoscope is difficult to teach. The McGrath videolaryngoscope, a Macintosh-like device with a camera, can be used as a direct laryngoscope to educate novices under supervision using the screen. We compared the effect on Macintosh laryngoscopy skills following training with a McGrath videolaryngoscope as a direct versus indirect laryngoscope.MethodsThirty-seven participants were randomized into direct and indirect groups according to the training method using a McGrath videolaryngoscope. Participants attempted Macintosh direct laryngoscopy in normal and difficult airway scenarios. The primary endpoint was the intubation time, and the rate of successful intubation, dental trauma, and difficulty were secondary outcomes.ResultsThe intubation time after education decreased significantly in both groups and was significantly shorter in the direct group than in the indirect group across time. The difficulty degree in the direct group was lower than that in the indirect group across time; however, the rate of dental trauma was not significantly different.ConclusionBoth direct and indirect laryngoscopy using a McGrath videolaryngoscope improved the performance of Macintosh direct laryngoscopy in novices, while direct laryngoscopy using a McGrath videolaryngoscope demonstrated better educational effects than indirect laryngoscopy.Registered at ClinicalTrials.gov (NCT03471975).

A simulation-based study evaluating the preparedness of interns' post-anaesthesia rotation in managing a failed obstetric intubation scenario: Is our training good enough?

Difficult or failed intubation of obstetric patients may be up to 8 times higher than in general surgical patients. A decline in obstetric intubation opportunities may be a contributing factor, resulting in reduced training opportunities for junior doctors, who therefore do not acquire airway management skills. To assess post-anaesthesia rotation interns' preparedness to manage a difficult/failed obstetric airway scenario. We recruited 49 interns, obtained informed consent and individually assessed them on a simulation-based scenario using a high-fidelity manikin. Two independent assessors scored participants using a checklist assessment and a global rating scale. After the simulation-based scenario, participants completed a questionnaire on their internship training, rated the simulation experience and received debriefing. The borderline regression method was used to determine the checklist pass mark. Analysis showed that 40% of interns passed. Correlation between assessors was strong for checklist scores and global ratings. The main reasons for failing were repeated attempts at intubation and failure to optimise the intubating position or conditions. There was concern regarding the infrequent use of a supraglottic airway device as a rescue. Twenty-eight interns had performed &lt;5 general obstetric anaesthetic procedures. There are concerns regarding adequate anaesthetic preparation for interns to manage a difficult/failed intubation scenario in a full-term pregnancy. Despite the Essential Steps in Managing Obstetric Emergencies (ESMOE) airway module training, which all interns should receive, a high rate of success was not achieved in this study. Simulation-based training and assessment may be a valuable tool to improve intern training and preparedness.

Awake intubation with C-MAC videolaryngoscope in a patient with difficult airway.

Sir, The role of videolaryngoscopy has increased in the management of the difficult airway in recent times. We report a case where C-MAC D-blade videolaryngoscope (VL) was used in the airway management of a patient with cervico-facial necrotising fasciitis scheduled for surgical debridement. A 28-year-old male patient was posted for surgical debridement of cervico-facial necrotising fasciitis with multi-organ dysfunction. He was a known case of type 1 diabetes mellitus (DM). On examination, the patient was irritable and disoriented due to sepsis-induced encephalopathy (GCS-E3V3M5). He had a swollen and blackened right cheek due to necrosis with extension to the neck [Figure 1]. The mouth opening of the patient was around 1.6cm with restricted neck mobility, eliminating the possibility of neck extension. Our primary airway management plan was awake intubation via C-MAC VL (Karl Storz) blade D. A fibre-optic bronchoscope with an endoscopic mask was readily available as an alternative airway management plan. A skilled ear-nose-throat (ENT) surgeon was also requested to be standby for the emergency tracheostomy.Figure 1: Cervico-facial necrotising fasciitis involving the entire right cheek and extending to the neckIn the preoperative room, the patient's airway was prepared by nebulisation with 4mL of 4% lignocaine. In the operating room, standard American Society of Anesthesiologists (ASA) monitors such as electrocardiogram, non-invasive blood pressure and pulse oximeter were attached to the patient. The patient was sedated with 50 μg fentanyl and dexmedetomidine (loading dose of 1 μg/kg, followed by the infusion of 0.5 μg/kg/h). The patient received continuous oxygen via a nasal catheter with a flow of 3 L.min−1. Topical anaesthesia was supplemented with two puffs of lidocaine 10% metered spray applied directly on the surface of the tongue and oropharynx. Videolaryngoscopy was done using an adult D-blade of C-MAC and the percentage of glottic opening (POGO) score was found to be zero. Simultaneously, the posterior pharyngeal wall was anaesthetised with two puffs of 10% lignocaine spray to blunt the reflexes during insertion of the endotracheal tube (ETT). The patient was then intubated with a 7.5 mm internal diameter (ID) ETT with the aid of Eschmann stylet (Portex; Smiths Medical). After confirmation of the capnography waveform, general anaesthesia was induced with propofol and rocuronium. The surgery lasted uneventfully for around 100 min after which the patient was shifted to the intensive care unit, and was extubated the same day. Cervico-facial necrotising fasciitis is a soft tissue infection that spreads along with the superficial musculoaponeurotic system and early aggressive surgical debridement is the mainstay in achieving a successful outcome.[1] Anaesthetic management of such patients is challenging as the pain, swelling and oedema due to inflammatory processes restrict the facial and cervical movements, making the airway potentially difficult. Awake fibre-optic intubation (AFOI) is considered the technique of choice in predicted difficult airway. AFOI has a steep learning curve and requires patient cooperation. Recently, VLs have gained immense popularity as the first-line devices in adult and paediatric difficult airways due to feasibility of orotracheal intubation in a restricted mouth opening.[23] Karmer et al. described C-MAC VL as superior to fibre-optic intubation (FOI) in terms of faster intubation time in limited mouth opening patients(>1.3cm).[4] Alhomary in a systematic review also confirmed that awake video laryngoscopy has a shorter intubation time compared to AFOI.[5] In our institute, we frequently use D-blade of C-MAC for difficult intubations and so are well versed with it. Hence, C-MAC was chosen as a primary airway management plan to quickly secure the airway. Since the D-blade has a thickness of around 1 cm, it can be easily accommodated in the limited mouth opening patient and has a better field of vision (60 degrees angle of view) with the requirement of less lifting force to visualise the glottis, especially in patients who are not fully anaesthetised.[6] To conclude, we suggest that awake videolaryngoscopy using D-blade of C-MAC VL can be considered as an alternative for tracheal intubation in difficult airway scenarios where AFOI is difficult or not possible. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgement We would like to acknowledge the support and guidance of Dr Rakesh Kumar, M.D, Associate Professor, Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur in helping me write this article.

Ease of intubation and incidence of dental injury during direct laryngoscopy: A randomized controlled trial comparing five different laryngoscope blades (Macintosh, Miller, Reduce flange, Blechman and Flangeless)

BackgroundDirect laryngoscopy remains an invaluable and readily available option despite the increasing use of video laryngoscope for securing the airway in different situations, particularly in limited resource and unanticipated difficult airway scenarios. Several variations of the laryngoscope blades are available for various purposes. However, knowledge of the functioning of different blades in a similar controlled environment is required because of the unavailability of all blades in a given setting. AimThis study assessed the ease of intubation and the degree of dental injury with five types of laryngoscope blades (Macintosh, Miller, Reduced flange, Blechman, and Flangeless blade). MethodsThis prospective randomized controlled study was conducted in patients undergoing tracheal intubation with direct laryngoscopy using five different blades posted for elective surgery under general anesthesia in a single center.The primary outcome parameters were Cormack–Lehane grade and intubation difficulty score, whereas secondary outcome measures were the proportion and grades of dental injury. ResultsA Cormack–Lehane grade 3 view was observed more often with flangeless blades 7 (22.5%) than others, with the lowest incidence for the Macintosh blade 1 (3%) (p = 0.228). The first pass success rate was highest in Macintosh (94%), similar in reduced flange Macintosh and Blechman blades (90% each) and least in the flangeless blade (77%). The force required for laryngoscopy varied significantly between the blades (p < 0.001). The median interquartile range intubation difficulty score was the highest with flangeless blades [2 (2–3)] among all the groups (p = 0.048). The dental contact during laryngoscopy varied significantly between the groups (p < 0.001). The incidence of dental injury was the highest in flangeless (13%) among all the blades (p = 0.526). ConclusionsReduced flange Macintosh and Blechman blade had ease of intubation similar to standard Macintosh blade, where as flangeless blade is associated with more difficult intubations. Reduced flange Macintosh, and Blechman blades were associated with a lower incidence of dental contact and injury than other three study blades.

One Lung Ventilation Using an Orotracheal Tube and an Endobronchial Blocker in a Patient with Difficult Airway

One-Lung Ventilation (OLV) is achieved in thoracic surgeries to facilitate collapse of one lung for better surgical visualisation. Double-lumen tubes and bronchial blockers are two commonly used devices for OLV. Patients with ‘difficult airway’ pose significant challenges for insertion of Double Lumen Endotracheal Tube (DLT). Dual malignancy such as carcinoma of lung and head and neck is extremely rare to present with. Patients presenting with restricted mouth opening due to previous surgeries and requiring lung isolation techniques may pose significant challenges to anaesthesiologist. The difficult airway scenario may arise in such patients owing to their previous surgery to the tongue, larynx, neck, mandible or previous radiation. The present case was of 47-year-old of lung isolation achieved in a patient with restricted mouth opening with an orotracheal tube, bougie, endobronchial blocker and a flexible Fibre Optic Bronchoscope (FOB). Left upper lobectomy was successfully performed after passing endobronchial blocker through a conventional orotracheal tube under the guidance of FOB.

Impact of aerosol box on intubation during COVID-19: a simulation study of normal and difficult airways.

PurposePatients with coronavirus disease (COVID-19) are at risk of requiring mechanical ventilation, and concerns of protecting healthcare workers during aerosol-generating medical procedures has led to the design of the aerosol box.MethodsWe conducted a randomized crossover mannequin-based simulation study to compare airway management with and without the aerosol box. Thirty-five anesthesiology participants and three critical care participants with more than 50 intubations with videolaryngoscopes were recruited. There were four airway simulations with and without the aerosol box (normal, pharyngeal swelling, cervical spine rigidity, and tongue edema). Each participant intubated the mannequin in eight consecutive simulations. The primary outcome of the study was time to intubation. Secondary outcomes included intubation attempts, optimization maneuvers, and personal protective equipment breaches.ResultsMean (standard deviation [SD]) time to intubation overall with the box was 30.9 (23.0) sec, while the time to intubation without the box was 25.1 (12.2) sec (mean difference, 5.8; 95% confidence interval [CI], −2.9 to 14.5). For the normal airway scenario, the mean (SD) time to intubation was 18.6 (3.5) sec for no box and 20.4 (3.3) sec for box (mean difference, 1.8; 95% CI, 0.2 to 3.4). During difficult airway scenarios only, the time to intubation was 34.4 (25.6) sec with the aerosol box and 27.3 (13.2) sec without the aerosol box (mean difference, 7.1; 95% CI, −2.5 to 16.7). There were more intubation attempts, personal protective equipment breaches, and optimization maneuvers during use of the aerosol box.ConclusionsIn this mannequin-based simulation study, the use of the aerosol box increased the time to intubation in some contexts but not others. Further studies in a clinical setting should be conducted to make appropriate modifications to the aerosol box to fully elicit its efficacy and safety prior to implementation in airway guidelines for managing patients with COVID-19.

Effect of an Aerosol Box on Intubation in Simulated Emergency Department Airways: A Randomized Crossover Study.

IntroductionThe use of transparent plastic aerosol boxes as protective barriers during endotracheal intubation has been advocated during the severe acute respiratory syndrome coronavirus 2 pandemic. There is evidence of worldwide distribution of such devices, but some experts have warned of possible negative impacts of their use. The objective of this study was to measure the effect of an aerosol box on intubation performance across a variety of simulated difficult airway scenarios in the emergency department.MethodsThis was a randomized, crossover design study. Participants were randomized to intubate one of five airway scenarios with and without an aerosol box in place, with randomization of intubation sequence. The primary outcome was time to intubation. Secondary outcomes included number of intubation attempts, Cormack-Lehane view, percent of glottic opening, and resident physician perception of intubation difficulty.ResultsForty-eight residents performed 96 intubations. Time to intubation was significantly longer with box use than without (mean 17 seconds [range 6–68 seconds] vs mean 10 seconds [range 5–40 seconds], p <0.001). Participants perceived intubation as being significantly more difficult with the aerosol box. There were no significant differences in the number of attempts or quality of view obtained.ConclusionUse of an aerosol box during difficult endotracheal intubation increases the time to intubation and perceived difficulty across a range of simulated ED patients.

VieScope® laryngoscope versus Macintosh laryngoscope during difficult intubation performed by paramedics: a randomized cross-over manikin trial

INTRODUCTION: The aim of this study was to evaluate intubation performance by paramedics using Macintosh laryngoscope and VieScope® laryngoscope under simulated difficult airway conditions. METHODS: In a randomized, single-blinded, cross-over simulation trial, 42 paramedics performed endotracheal intubation using VieScope® and Macintosh (MAC) laryngoscopes in two difficult airway scenarios: (A) tongue edema, (B) manual cervical inline stabilization. The order of participants and intubation methods was random. Time to ventilation constituted the primary outcome, and the secondary outcomes were the success rate of first intubation attempt, overall intubation success rate, Cormack and Lehane grade, and ease of use. RESULTS: In scenario A, the median overall intubation time was 55s (46–109) in the MAC group and 30.5s (26–35) in the VieScope® group (p < 0.001). The efficacy of the first intubation attempt with MAC and Vie- Scope® varied and amounted to 64.3% vs. 95.2% (p < 0.001). During scenario B, VieScope® offered better intubation conditions than MAC (p < 0.001), including shorter intubation time, higher first attempt and overall intubation success rates, as well as better glottic view. CONCLUSIONS: In this simulation trial, we found that VieScope® could be successfully used for intubation in difficult airways by paramedics with little simulation experience with this device. VieScope® was associated with shorter time and higher success rates of intubation attempt compared with MAC. Nevertheless, we recommend that the performance of VieScope® and MAC should be further evaluated in the clinical setting to confirm our results.