Airway Scenarios Research Articles

Can use of video Laryngoscopes by Emergency Medical Technicians Facilitate Endotracheal Intubation during Continuous Chest Compression? A Manikin Study

Introduction We conducted this study to evaluate the utility of two video laryngoscopes (VLs) [Pentax-AWS (AWS), GlideScope (GVL)], compared to the conventional Macintosh laryngoscope (ML), on endotracheal intubation (ETI) involving chest compressions by Level 1 Korean emergency medical technicians (EMTs) who are the equivalent of EMT-I in the United States. Methods This was a randomised crossover simulation study. Fifty EMTs performed endotracheal intubation in randomised sequence following two different scenarios: normal airway and difficult airway. Results In normal airway scenario, overall success rate did not differ between the three devices. However AWS required a shorter run-time (14.1 [10.9-19.8] seconds) to complete ETI (TC) than ML (17.7 [13.5-21.3] seconds) (p=0.017). And both VLs showed a significant superiority over ML in time required to visualise vocal cords (TVC), percentage of glottic opening (POGO) score, and incidence of dental compression (IDC). In difficult airway scenario, overall success rate of both VLs was significantly higher than ML. The TC of AWS (13.7 [11.2-16.9] seconds) and GVL (20.7 [15.1-25.9] seconds) was shorter than that of ML (24.7 [18.1-34.5] seconds) (p<0.001). The TVC of GVL was significantly shorter than that of AWS and ML. The POGO score, IDC, and ease of intubation were significantly superior with AWS, GVL, and ML, respectively. Conclusions Video laryngoscopes can facilitate EMT performing a faster and easier intubation without interrupting chest compressions. Moreover, AWS improves the success rate comparing to ML in difficult airway management. (Hong Kong j.emerg.med. 2014;21:308-315)

Can the new McGrath laryngoscope rival the GlideScope Ranger portable video laryngoscope? A randomized manikin study

PurposeWe hypothesized that novices would be able to use the McGrath MAC (Aircraft Medical Ltd, Edinburgh, UK) equally as well as the GlideScope Ranger (Verathon, Inc, Bothell, WA) for intubation in regular simulated airways. MethodsWe performed a prospective, randomized crossover study of 39 medical students using the McGrath MAC, GlideScope Ranger, and Macintosh in a manikin with 2 normal airways. The primary outcome was the intubation time. Secondary outcomes included the success rates and the overall glottic view of the 3 laryngoscopes. ResultsThe mean intubation times for each attempt with the McGrath MAC were 30.8 ± 16.9 seconds or less and did not differ significantly from those obtained with the GlideScope Ranger or the Macintosh in both airway scenarios (P = .18; P = .49). The mean success rates at each attempt with the McGrath MAC were 82.0% ± 38.8% or more, equal to the Macintosh and the GlideScope Ranger in both scenarios (P = .026; P = .72) except during the first intubation attempt in a normal airway (P = .008). The median grades of the glottic view visible at each intubation attempt with the McGrath Mac were Cormack-Lehane grade 1 (scenario 1: interquartile range, 1-1; scenario 2: interquartile range, 1-2), which was significantly better than the Macintosh laryngoscope in both scenarios. However, the McGrath Mac did not produce a better glottic view than the GlideScope Ranger with either scenario. ConclusionsThe intubation performance of novices using the McGrath MAC was equal to their performance using the GlideScope Ranger in regular simulated airways.

Successful intubation with Macintosh laryngoscope after failed intubation with McGrath videolaryngoscope in post burn contracture of the neck

A 29 year old woman, a case of post burn contracture of the neck came for the release. McGrath video laryngoscope was chosen as the initial tool for airway management. Despite an excellent view, intubation failed due to lack of working airway space available after use of video laryngoscope. Successful intubation was achieved with Macintosh laryngoscope although the laryngoscopy view was Cormack and Lehane grade IIIa and percentage of glottic opening score was 25%. More research into the predictors of difficult laryngoscopy or intubation with the video laryngoscope needs to be done before recommending these devices for use in difficult airway scenarios. DOI: http://dx.doi.org/10/4038/slja.v22i2.6833

Airway skills training using a human patient simulator

Background: Airway skills education is important for the safe and effective care of patients. Interns often encounter critical airway situations. Their ability to cope derives from the recall of formal lectures and tutorials, as well as accumulated experience. We tested whether human patient simulators enabled trainees to enhance skills and knowledge in a safe and realistic environment.Method: An airway training programme was developed using a high-fidelity lifelike human patient simulator (METI®) to simulate realistic airway scenarios. An equivalent programme using traditional methods (lectures and tutorials) contained the same information. A written assessment [(multiple-choice questions (MCQ)] and four assessment stations [objective structured clinical examination (OSCE)] were administered before and after instruction. A questionnaire documented previous exposure to the simulator, airway management techniques and devices, and participants’ subjective opinions on the instruction received.Results: Eighty-two participants were enrolled into two groups of 41. Groups were comparable in terms of previous exposure and experience, as well as in pre-training scores. Both groups showed significant improvement in post-training scores. However, subjects receiving simulator training achieved significantly higher test scores in the MCQ (median 43 out of 50, interquartile range (IQR) 42–45, versus 41 out of 50, IQR 39–43); and OSCE assessment station 3 (median 15 out of 15, IQR 13–15, versus 14 and 12–15), and OSCE assessement station 4 (median 13 out of 15, IQR 12–14, versus 12 and 10–13). The simulator group showed greater participant satisfaction (95% vs. 34%).Conclusion: There was improved immediate retention of knowledge and performance of airway management skills using the simulator. Participant satisfaction was much better in the simulator group. The importance of psychomotor reinforcement should be borne in mind when designing simulation courses.

The LMA-Supreme versus the I-gel in simulated difficult airway in children

Supraglottic airway devices such as the LMA-Supreme (LMA-S) and I-gel, which have an additional lumen for the insertion of a gastric tube, can be useful in the management of the difficult airway. To test the performance of these two devices in the difficult paediatric airway. Randomised double-blind study. Anaesthesia department, university hospital. Sixty American Society of Anesthesiologists (ASA) I-II children undergoing elective surgery. After obtaining ethical approval and written informed consent from the parents, we compared the size 2 LMA-S with the I-gel in a simulated airway scenario made more difficult by using a cervical collar to limit mouth opening and neck movement. The primary aim was to compare the oropharyngeal leak pressure of the LMA-S and the I-gel. The secondary aims were to compare success rate, insertion time, time to pass a gastric tube and fibreoptic view of the larynx. Oropharyngeal leak pressure (mean ± SD) for the LMA-S was significantly higher than with the I-gel (20.9 ± 3.2 versus 18.9 ± 3.2 cmH2O, P = 0.019). First attempt success rate for the LMA-S was 100 and 90% for the I-gel (P > 0.05). Insertion time of the LMA-S was shorter than I-gel (11.2 ± 1.8 versus 13.5 ± 2.4 s, P = 0.001). Gastric tube placement was possible in all patients. The mean insertion time of the gastric tube was shorter with the LMA-S than with the I-gel (10.3 ± 3.6 versus 12.7 ± 3.2 s, P = 0.009). Fibreoptic laryngeal views were similar in both groups. In the simulated difficult airway in children, both airway devices provided effective ventilation. Paediatric size 2 LMA-S sustained a higher airway pressure before leaking and was quicker to insert than the I-gel equivalent. These differences may not be clinically significant.

Is McGrath® MAC better than Glidescope® Ranger for novice providers in the simulated difficult airway? A randomized manikin study

Purpose of this study:McGrath® MAC and Glidescope® Ranger are portable video laryngoscopes that are easy to learn for novice and useful in difficult airway environment. We anticipated that McGrath® MAC would show performance in intubation of novices as equal as Glidescope® Ranger in normal and difficult airway. Materials and Methods: Primary outcomes were the rate of successful intubation, intubation time and overall glottic view of McGrath® MAC,Glidescope® Ranger andMacintosh.Weperformed a prospective, single-blinded, randomized crossover study of 39 medical students using three laryngoscopes in amanikin,with simulated normal and difficult airway scenarios. Results: The successful intubation rate of McGrath® MAC (82.5 (38.5)%) was better than Macintosh (57.5 (50.1)%; p=0.026) and equal to Glidescope® Ranger (85 (36.2)%) at first attempt of easy scenario. However, McGrath® MAC was equal to Macintosh and Glidescope® Ranger from second to fifth attempt. The intubation timeofMcGrath® MAC (24.4 (14.7) s)was also equal toGlidescope® Ranger (22.2 (8.7) s) and Macintosh laryngoscopes (25.4 (12.2) s). The glottic view ofMcGrath® MAC (1 (1–1))was superior toMacintosh (2 (1–2); P=0.000) and equal to Glidescope® Ranger (1 (1-1)). Novicesachievedanequal successful intubation ratewhenusing the McGrath® MAC (94.9 (22.1)%) comparing with Glidescope® Ranger (93.3 (25)%) and Macintosh (92.3 (26.7)%) in difficult scenario (p=0.725). Intubation times were also similar for three laryngoscopes and became shorter with practice (p=0.000). The view at laryngoscopy with the McGrath® MAC was better than Macintosh (p=0.000) and not superior to Glidescope® Ranger (p=0.001). Conclusions: The rate for successful intubation and intubation time with McGrath® MAC in novices were equal to Glidescope® Ranger and Macintosh laryngoscope. Novices achieved a better glottic view with McGrath® MAC than Macintosh and not in comparison to Glidescope® Ranger in both of airway environments.

Comparison of the King Vision Video Laryngoscope with the Macintosh Laryngoscope

BackgroundEndotracheal intubation is a common procedure in the emergency department, and new devices may improve intubation time, success, or view. ObjectiveWe compared the King Vision video laryngoscope (KVVL; King Systems, Noblesville, IN) to the Macintosh direct laryngoscope (DL) in simulated normal and difficult airways. MethodsUsing manikins and clinical-grade cadavers, difficult airway scenarios were simulated using head movement restriction or a cervical spine collar. Four scenarios were studied using the KVVL and DL: normal manikin airway, difficult manikin airway, normal cadaver airway, and difficult cadaver airway. Primary outcomes were time to intubation and rate of successful intubation. Secondary outcomes were the percent of glottic opening and Cormack-Lehane grade visualized. ResultsThirty-two paramedics participated in the study. In the normal manikin airway scenario, time to intubation was 3.4 s (99% confidence interval [CI] 0.1–6.6) faster with the KVVL compared with DL. Time to intubation was 11.3 s (99% CI 2.4–20.2) faster with the KVVL in the difficult cadaver airway scenario. There was no difference in time to intubation in the other 2 scenarios. In the difficult cadaver airway, 10 of 32 participants failed to successfully intubate the trachea using DL, whereas all KVVL intubations were successful. All scenarios found a lower Cormack-Lehane grade and higher percentage of glottic opening with the KVVL compared to DL. ConclusionThe KVVL was slightly faster than Macintosh DL in two of four studied airway scenarios, and had a higher success rate in the difficult cadaver airway scenario. Further study is required in the clinical setting.

Tracheal intubation with a flexible fibreoptic scope or the McGrath videolaryngoscope in simulated difficult airway scenarios

Flexible fibreoptic endoscopic (FFE) intubation is considered the 'gold-standard' when difficult airway management is anticipated. Several videolaryngoscopes have been developed to facilitate intubation by laryngoscopy. The aim of the study was to compare the performance of the McGrath series 5 videolaryngoscope (McGrath videolaryngoscope) and the FFE for tracheal intubation in manikins with a simulated difficult airway, hypothesizing that the McGrath videolaryngoscope intubation would prove faster than FFE intubation. A randomised controlled study. The Danish Institute for medical simulation between December 2009 and June 2010. Twenty-eight anaesthesia residents participating in the Danish mandatory 3-day airway management course. All participants received instructions and training in the use of the McGrath videolaryngoscope and FFE. The participants then performed tracheal intubation on a SimMan manikin once with the McGrath videolaryngoscope and once with the FFE in three difficult airway scenarios: (1) pharyngeal obstruction; (2) pharyngeal obstruction and cervical rigidity; (3) tongue oedema. We measured successful intubations, defined as intubation within 120 s, and time to tracheal intubation. The trachea was intubated within 120 s with the McGrath videolaryngoscope in 25 out of 27 (93%), 25 out of 28 (89%) and 18 out of 28 (64%) occasions compared with 11 out of 28 (40%), 11 out of 28 (40%) and 16 out of 28 (57%) with the FFE in scenarios (1), (2) and (3), respectively. Time to tracheal intubation was shorter with the McGrath videolaryngoscope in scenarios (1) and (2) than with the FFE (Wilcoxon signed rank sum test, P < 0.0001). The McGrath videolaryngoscope is a valuable device with higher success rate and a quicker performance in simulated difficult airways. In patients, videolaryngoscopy may have a role in difficult airway algorithms, but the optimal device has yet to be found.

Comparison of the glidescope®, flexible fibreoptic intubating bronchoscope, iPhone modified bronchoscope, and the Macintosh laryngoscope in normal and difficult airways: a manikin study

BackgroundSmart phone technology is becoming increasingly integrated into medical care.Our study compared an iPhone modified flexible fibreoptic bronchoscope as an intubation aid and clinical teaching tool with an unmodified bronchoscope, Glidescope® and Macintosh laryngoscope in a simulated normal and difficult airway scenario.MethodsSixty three anaesthesia providers, 21 consultant anaesthetists, 21 registrars and 21 anaesthetic nurses attempted to intubate a MegaCode Kelly™ manikin, comparing a normal and difficult airway scenario for each device. Primary endpoints were time to view the vocal cords (TVC), time to successful intubation (TSI) and number of failed intubations with each device. Secondary outcomes included participant rated device usability and preference for each scenario. Advantages and disadvantages of the iPhone modified bronchoscope were also discussed.ResultsThere was no significant difference in TVC with the iPhone modified bronchoscope compared with the Macintosh blade (P = 1.0) or unmodified bronchoscope (P = 0.155). TVC was significantly shorter with the Glidescope compared with the Macintosh blade (P < 0.001), iPhone (P < 0.001) and unmodified bronchoscope (P = 0.011). The iPhone bronchoscope TSI was significantly longer than all other devices (P < 0.001). There was no difference between anaesthetic consultant or registrar TVC (P = 1.0) or TSI (P = 0.252), with both being less than the nurses (P < 0.001). Consultant anaesthetists and nurses had a higher intubation failure rate with the iPhone modified bronchoscope compared with the registrars. Although more difficult to use, similar proportions of consultants (14/21), registrars (15/21) and nurses (15/21) indicated that they would be prepared to use the iPhone modified bronchoscope in their clinical practice. The Glidescope was rated easiest to use (P < 0.001) and was the preferred device by all participants for the difficult airway scenario.ConclusionsThe iPhone modified bronchoscope, in its current configuration, was found to be more difficult to use compared with the Glidescope® and unmodified bronchoscope; however it offered several advantages for teaching fibreoptic intubation technique when video-assisted bronchoscopy was unavailable.

Impact of Difficult Airway Training on Performance of Korean Paramedic Students in Simulated Normal and Difficult Airway Scenarios: A Randomized Educational Intervention Study

Impact of Difficult Airway Training on Performance of Korean Paramedic Students in Simulated Normal and Difficult Airway Scenarios: A Randomized Educational Intervention Study

Endotracheal intubation with a video-assisted semi-rigid fiberoptic stylet by prehospital providers

Emergency medical technicians intubate patients in unfamiliar surroundings and with less than ideal positioning. This study was designed to evaluate advanced life support (ALS) emergency medical technicians' (EMTs) ability to successfully intubate a simulated airway using a video-assisted semi-rigid fiberoptic stylet, the Clarus Video System (CVS). ALS EMTs were first shown a brief slideshow and three example videos and then given 20 min to practice intubating a mannequin using both the CVS and standard direct laryngoscopy (DL). The mannequin was then placed on the floor to simulate field intubation at the scene. Each participant was given up to three timed attempts with each technique. Endotracheal tube position was confirmed with visualization by one of the study authors. Comparisons and statistical analysis were conducted using SPSS® Statistics 21 (IBM®). Demographics and survey results were also collected and analyzed. The median total time for intubation was 15.00 s for DL and 15.50 s for CVS revealing no significant difference between the two techniques (p = 0.425), and there was no significant difference in the number of attempts required to successfully place the endotracheal tube (ETT) (p = 0.997). Demographic factors including handedness and eye dominance did not seem to affect outcomes. Participants reported a relatively high level of satisfaction with the CVS. ALS EMTs were able to obtain intubation results similar to those of their usual direct laryngoscopy technique when utilizing a video-assisted semi-rigid fiberoptic stylet with very limited instruction and experience with the device. The CVS technique warrants further study for use as an alternative to DL and video laryngoscopy in the prehospital difficult airway scenario.

Traumatic rupture of a nasoethmoidal meningoencephalocele in an adult following a difficult airway scenario

SummaryIntranasal meningoencephaloceles are characterised by protrusion of brain and meninges through a skull‐base defect. Nasal intubation or instrumentation may lead to complications such as meningoencephalitis and cerebrospinal fluid rhinorrhoea or fistula formation. A 62 year old lady developed rhinorrhea following failed videolaryngoscopic and nasal fibreoptic intubation, which ultimately necessitated emergency surgical tracheostomy for a “can't intubation can't ventilate” scenario. This case highlights the diagnosis and management of an unusual complication resulting from difficult airway management.

A Retrospective Study of the Performance of Video Laryngoscopy in an Obstetric Unit

We evaluated the performance of tracheal intubation using video laryngoscopy in an obstetric unit. We analyzed airway management details during a 3-year period, and observed 180 intubations. All cases were managed with direct or video laryngoscopy. Direct laryngoscopy resulted in 157 out of 163 (95% confidence interval [CI], 92%-99%) first attempt successful intubations and failed once. Video laryngoscopy resulted in 18 of 18 (95% CI, 81%-100%) successful intubations on first attempt. The failed direct laryngoscopy was rescued with video laryngoscopy. The patients managed with video laryngoscopy frequently required urgent or emergency surgery and had predictors of difficult direct laryngoscopy in 16 of 18 cases. Video laryngoscopy may be a useful adjunct for obstetric airway management, and its role in this difficult airway scenario should be further studied.

Evaluation of Paramedic Utilization of the Intubating Laryngeal Mask Airway in High-Fidelity Simulated Critical Care Scenarios

Successful oxygenation and ventilation can mean the difference between life and death in the prehospital setting. While airway challenges can be numerous within the confines of the emergency department, there are many additional confounding difficulties in the prehospital setting, which include limited access to equipment, poor lighting, extreme environments, limited personnel to assist, no immediate backup, and limited rescue airway options. The concept of an easy, reliable, and rapidly deployable alternative rescue airway device is critical, especially when considering the addition of rapid sequence intubation protocols in the prehospital setting. Hypothesis The primary objective of this study was to ascertain whether paramedics can be trained to deploy this alternative airway device with an acceptable success rate in a simulated critical care airway scenario. The secondary objective was to determine whether the previously-trained paramedics were able to retain their ability to deploy the device successfully at one year. This was a prospective, observational, single-group, descriptive cohort, educational trial. Forty paramedics were trained in the use of the Intubating Laryngeal Mask Airway (I-LMA) in a simulation medicine curriculum culminating in a simulated critical care difficult airway scenario requiring urgent oxygenation and ventilation after failed traditional endotracheal intubation. An emergency medicine physician proctor determined successful airway management. Repeat testing was then performed at approximately one year out, challenging the medics to intubate a mannequin using the I-LMA during an unrelated training session. Of the 40 paramedics who underwent complete simulation training, 39 were able to intubate and ventilate the simulated difficult airway using the I-LMA during the critical care scenario. This yields a success rate of 97.5% (95% CI, 87.1%-99.4%). At approximately one year out, 35 out of 35 medics were able to intubate the mannequin using the I-LMA, resulting in a success rate of 100% (95% CI, 91.4%-100%). In this study, paramedics were able to deploy the I-LMA with a high degree of success in a simulated difficult airway, with a high degree of skill retention at one year out.

Comparison of the Macintosh, McCoy, Airtraq laryngoscopes and the intubating laryngeal mask airway in a difficult airway with manual in-line stabilisation

Patients with multisystem trauma undergoing intubation with manual in-line stabilisation (MILS) have a higher incidence of difficult or failed intubations. To compare the effectiveness of the Macintosh laryngoscope with three other intubating devices in a high fidelity simulation model. Cross-over, simulation-based study. Tertiary referral and level 1 trauma centre between June and November 2011. Thirty-five experienced airway physicians. Each participant performed tracheal intubations on a Laerdal SimMan manikin in both a normal airway and a difficult airway scenario with MILS. The devices utilised in a randomised order were the Macintosh, McCoy, Airtraq laryngoscopes and the intubating laryngeal mask airway (iLMA). The primary outcome was time to intubation. Success rates, grade of laryngoscopy and force of intubation were also measured. One hundred and forty intubations were attempted by 35 participants in both the normal and MILS scenarios. In the normal airway, there was no difference in success rates and time to intubation. In the difficult airway with MILS, there was no difference in success rates. However, the Airtraq was associated with a longer time to intubation than the Macintosh, McCoy and iLMA, 39.3, 26.7, 23.3, 39.3, 22.8 s, respectively (P < 0.0001). The Airtraq delivered the best glottic view and lowest force of intubation in both scenarios (P < 0.0001), but was associated with the only failed intubation in the study. The McCoy was associated with a significant improvement in the glottic visualisation (P < 0.05) and reduction in the force of intubation (P <0.0001) compared with the Macintosh. In this manikin study, the McCoy demonstrated multiple advantages over the Macintosh. The iLMA was associated with the fastest time to intubation and minimum force of insertion.

Parker Flex-It intubation stylet versus a 90-degree curved stylet during intubation with the McGrath videolaryngoscope performed by novices: a manikin study with 5 airway scenarios

Study ObjectiveTo compare the Parker Flex-It intubation stylet with a 90-degree curved stylet using the McGrath videolaryngoscope in 5 airway scenarios (from easy to difficult) in a manikin. DesignProspective, randomized study. SettingAcademic hospital. Subjects20 staff anesthesiologists with no previous experience in videolaryngoscopy. MeasurementsSubjects performed a total of 200 intubations with the McGrath Series 5 videolaryngoscope and completed a questionnaire afterwards. ResultsOverall success rate was significantly higher with the Parker Flex-It intubation stylet (96 successful intubations with the Parker Flex-It vs 79 intubations in the 90° curved stylet group; P < 0.05). Intubation time was not significantly different. Subjects rated the Parker Flex-It intubation stylet as the better device for intubation with the McGrath videolaryngoscope in routine or emergency situations. ConclusionIntubation of the manikin with the McGrath videolaryngoscope had more success with the Parker Flex-It intubation stylet than a 90° curved stylet.

Sugammadex to rescue a ‘can't ventilate’ scenario in an anticipated difficult intubation: is it the answer?

Sugammadex to rescue a ‘can't ventilate’ scenario in an anticipated difficult intubation: is it the answer?

Ventilation with a view and usefulness of Airtraq laryngoscope

Editor, We read with interest the observational controlled study by Legrand et al.1 comparing a modified Macintosh blade with Airtraq and Bullard laryngoscopes published in the Journal. As the study so beautifully shows, intubation success is low in the very difficult airway scenario with the Airtraq laryngoscope (20% for beginners and 50% for experts). The study shows a much better valuation for Bullard laryngoscope (87 and 97% intubation success in beginners and experts, respectively). We wish to point out that the 0.1 to 0.3% failed intubation rate2 quoted in the study actually raises serious doubt as to the power of the study. Observational studies for medical equipment have to take into consideration what failure rate for the equipment is acceptable. In this study with one failure in 60 practitioners, the failure rate of conventional laryngoscopy in the manikin was 1.6% for a moderately difficult airway. For Airtraq and Bullard laryngoscopes, to attain a failure rate equal to or less than this in this scenario, the study would require more than 250 cases before the question can be answered with satisfaction.3 Thus, the apparent 100% success rate with Airtraq and Bullard laryngoscopes in scenario A (moderate difficult intubation) cannot be taken seriously as it will need at least 250 cases before a failure is noted if we are looking at a failure rate of less than 1.6%. There are no data on failure rates in scenario B (very difficult airway) except on manikins. With the high failure rates observed with Airtraq and Bullard laryngoscopes and the gravity of the situation, it might be worthwhile instead to find out how fibreoptic intubation would perform in this situation. We would also like to point out that there are some more practical issues faced in such scenarios that need to be considered before we conclude as to the usefulness of either of these devices in the very difficult airway situation. The most important issue if one cannot intubate as in any difficult airway scenario is if one can manually ventilate the patient to maintain oxygenation! This is the fact that might make or break the situation. Previously, it had been shown that the endotracheal tube loaded on an Airtraq can be used as a conduit to flush oxygen as a method to avoid fogging.4 We wish to point out that the patient can be ventilated as well via the endotracheal tube loaded on an Airtraq laryngoscope as done by us successfully in three anticipated difficult intubation situations (which were not a difficult to ventilate situation through facemask though). Thus, Airtraq may continue to be a very useful airway adjunct unlike the impression given in the study. This new method of ventilating the patient while waiting for optimising the patient and equipment to deal with the difficult intubation does, however, need further evaluation. Acknowledgements Assistance with the study: none declared. Financial support and sponsorship: none declared. Conflicts of interest: none declared. Comment from the editor: Dr Legrand and colleagues did not wish to reply to this letter.

Comparison of LMA-Supreme and i-gel in children: difficult airway scenario

Comparison of LMA-Supreme and i-gel in children: difficult airway scenario

How do Anaesthetists in New Zealand Disseminate Critical Airway Information?

The communication of information concerning patients with difficult airways is universally recognised as an important component in avoiding future airway management difficulties. A range of options is available to impart this information; little is known however, about the follow-up patterns of anaesthetists following the identification and management of a difficult airway. In this study, 158 anaesthetists were contacted and asked to comment on their follow-up patterns regarding a number of difficult airway scenarios. This was followed by a retrospective survey of 124 patients with known difficult airways. A wide discrepancy was found between stated follow-up preferences by anaesthetists and the actual use of options such as postoperative visits, notes in the clinical record, letters to the patient and family doctor, and entries in hospital, national and MedicAlert™ databases. Of the patients with an airway difficulty noted on their anaesthetic record, only 14% of them also had a pertinent comment on their clinical record; even fewer were referred to hospital warning systems (12%) or national (6%) and MedicAlert (7%) databases. Comments from our survey were critical of multiple difficult airway databases and alert systems, which are not linked and do not lead automatically to a single source of information. We suggest that a custom-designed MedicAlert New Zealand difficult airway/intubation registry could be established, with easy access for medical practitioners and patients. This registry could be accessed through the National Health Index database and linked to the MedicAlert international registry and their nine international affiliates.