Blind Intubation Research Articles

A study of BlockBuster laryngeal mask airway versus Fastrach/Intubating laryngeal mask airway as a conduit for blind oro-tracheal intubation: A prospective randomized controlled study

A Laryngeal Mask Airway (LMA) has two parts, a simple breathing tube and a mask. The mask at the laryngeal end of the tube aligns against the glottis and provides better channel of ventilation than the face mask. There have been modifications in the basic design of the LMA to incorporate gastric drainage channel and some devices are also equipped with a channel for intubation to secure airway by guiding endotracheal tube (ETT) through it. In this study we evaluated the performance of two LMA devices that can aid in rescue ventilation and are also equipped with a channel for intubation namely the BlockBuster LMA(2012) and the Fastrach/ Intubating LMA(1997) for blind oro-tracheal intubation in terms of First attempt success rate and Over-all success rate of intubation. A hundred consenting patients of age group 18-60 years and ASA status I or II, were randomly allocated into two groups Group BB (BlockBuster LMA) and Group FT (Fastrach LMA) with 50 patients each. Standard anesthesia technique was used for both groups. After insertion of airway device, cuff was inflated and ventilation was attempted (maximum 2 attempts). Once ventilation was achieved, ETT of appropriate size was inserted through LMA (maximum 2 attempts). The correct placement of ETT was confirmed by capnography. Data was collected for number of attempts of tracheal intubation, time taken for intubation and complications. First attempt success rate of intubation was more in Blockbuster LMA than Fastrach LMA. Over-all success rate of Intubation was 100% for both devices. Time taken for intubation and incidence of post-operative sore throat was less in BlockBuster LMA than Fastrach LMA(p-value<0.05). Blockbuster LMA is better conduit for oro-tracheal intubation than Fastrach LMA in terms of higher first attempt success rate, lesser time taken for intubation and lesser post-operative complications.

Comparative study of intubating LMA and I-gel for ease of insertion and as a conduit for endotracheal intubation

Background: A recently introduced supraglottic airway device (SAD) has been claimed to be an efficient supraglottic airway. It can also be used as a conduit for endotracheal intubation. However, LMA frequently used for this purpose; hence in this randomized study, success rate of blind tracheal intubation through two different SADs i-gel and LMA was evaluated. Methods: This is a prospective study was conducted in the Department of Anesthesia at Sapthagiri Institute of Medical Sciences & Research Centre among 140 patients fulfilling the criteria. Fasting patients with ages 20-50 years undergoing elective procedures under general anesthesia with ASA physical status 1 and 2 and Mallampatti class I and II were included in the study. Whereas patients with ASA physical status 3 or 4, and having contraindications to insertion of LMA or i-gel™ such as; mouth opening less than 2 cm, increased risk of aspiration, anticipated difficult intubation and facemask ventilation, with Mallampatti class III to IV were excluded. Results: One of the groups was administered the I-gel (Group G) and the other group was given I-LMA (Group L). Two groups were statistically similar in terms of distribution of ASA physical status grading (p<0.05). Two groups were statistically similar in terms of mallampati score distribution. Distribution of duration of surgery was not statistically significant in both the groups (p>0.05). It was observed that insertion I-gel was easy in 50 out of 70 patients. Difficulin 56 out of 70 patients. Difficult to insertion took place in 14 patients. The comparison of ease of insertion between the two groups did not reveal any statistical significance (p>0.05). Conclusion: We concluded I-gel aids easy and rapid insertion as a supraglottic airway device, but when it is used as a conduit for blind endotracheal intubation, the failure rate is high as there is more incidence of oesophageal intubation. On the contrary, ILMA being a gold standard device meant for intubation guide has a high first attempt success rate for blind endotracheal intubation.

S2649 Severe Gastrointestinal Bleeding Following Transesophageal Echocardiography and Ablation for Atrial Fibrillation: A Case Report

Introduction: Transesophageal echocardiograms (TEE) are performed to evaluate a variety of cardiac disorders. It involves blind intubation of the esophagus and carries a small risk of esophageal injury. This case describes a case of severe upper gastrointestinal bleeding (GIB) following TEE and ablation for atrial fibrillation. Case Description/Methods: A 66-year-old male with a history of atrial fibrillation and upper GI bleeding underwent TEE with ablation with the intention of doing a Watchman procedure in the future. Anticoagulation had been resumed two weeks prior to the procedure. The patient underwent ablation and shortly afterwards had hematemesis followed by an episode of melena. The hemoglobin fell from 11.2g/dl to 8.7g/dl and the patient required vasopressor support and transfusion. EGD revealed many 2-3 mm non-actively bleeding erosions with clots at their bases throughout the entire esophagus, with a large blood clot found in the cardia and gastric body (Figure). Although no active bleeding was noted, the patient continued to have a hemoglobin drop so a CT angiogram was performed which was unrevealing. The patient was managed conservatively and stabilized with no further episodes of bleeding, and his anticoagulation was eventually resumed without further complications. Discussion: This case illustrates the occurrence of gastrointestinal erosions and bleeding following TEE and ablation. Severe gastrointestinal hemorrhage is a rare but known adverse event associated with TEE and ablation. The incidence of TEE-related hemorrhage has been estimated to be between 0.02% to 1.0% and is often due to direct mucosal trauma1. Ablation may also induce thermal injury to the esophagus due to the proximity of the posterior left atrium and esophagus, causing esophageal ulcerations that can potentially lead to more serious complications such as atrioesophageal fistulae2. Caution should be taken when evaluating patients planned for such procedures, especially those with history of prior GIB, and anticoagulation should be held if possible.Figure 1.: A: Non-actively bleeding 3mm erosion with clot at its base in the upper third of the esophagus. B: Large blood clot in the gastric body.

Air-Q ILA as a conduit for orotracheal intubation in children: A randomized control trial for comparison between supine and lateral patient positions.

Airway management in children is always challenging and becomes a concern if required in the lateral position. We evaluated the efficacy of orotracheal intubation using the Air-Q intubating laryngeal Airway (Air-Q ILA) in supine and lateral positions in children. This study included 100 children weighing 7-30 kg, scheduled for elective surgeries under general anesthesia. They were randomized into the supine (S) group or lateral (L) group. After anesthesia induction, the child was placed in a standard sniffing position for conventional laryngoscopy in the S group, and the child was turned into the lateral position in the L group. Both Air-Q ILA and endotracheal tube were placed blindly in the supine position in the S group and lateral position in group L. The grading of glottic view, success rate, insertion time of the Air-Q ILA, and endotracheal intubation were noted in both the groups. The Air-Q ILA was successfully placed at the first attempt in 47 children in group S and 48 in group L. The overall blind orotracheal intubations, including first and second attempts, were successful in 45 children in the S group and 47 in the L group (P = 0.715). Eighty percent of patients in group L and 70% in group S had glottis grade 1 or 2 compared to grade 3, 4,5 (P = 0.249). The mean time of Air-Q ILA placement in groups S and L was 15.73 ± 5.64 s and 14.42 ± 4.16 s (P = 0.195). The mean duration of blind endotracheal intubation through the Air-Q ILA was 24.88 ± 14.75 s in group S and 17.57 ± 5.35 s in group L (P = 0.002). In both the groups, none of the children had bronchospasm, laryngospasm, desaturation, or aspiration. The airway trauma evident by blood staining on the Air-Q ILA on removal was revealed in 2 cases in group S, and 3 cases in group L. None of the children in group S and 4 children in group L had postoperative stridor. Postoperative hoarseness was reported in 3 children in group S and none in group L within 24 hours. The Air-Q ILA can be used as a conduit for blind orotracheal intubation in children in both supine and lateral positions while maintaining an effective airway seal.

Double-lumen Tube Position Confirmation with Fiberoptic Bronchoscope after Turning Patients into Lateral Position: Is It Necessary?

Background: Our goal was to compare two common methods including auscultation and Fiber-Optic Bronchoscopy (FOB) in confirming the correct placement of Double-Lumen Tube (DLT).
 Methods: Seventy six patients were enrolled. After DLT insertion, clinical verification was made by auscultation, then FOB was applied. At lateral decubitus, the position of DLT was rechecked by auscultation, and then by FOB. The incorrect position including malposition and misplacement were compared between two routine methods of auscultation and FOB.
 Results: After blind intubation, 21.1% of DLTs were considered to be in an incorrect position. Meanwhile, FOB showed that 46.1% of DLTs were not placed correctly. Among all the patients, 53.9% of DLTs were in the optimal position. Misplacement was diagnosed in 35.5% and malposition in 10.5% of the patients. After positioning to the lateral decubitus, using auscultation, we found that 5.3% of tubes were dislocated, but according to FOB, it was 10.5%. The agreement coefficient between auscultation and FOB was 0.42 in the supine position and 0.64 in lateral position.
 Conclusion: Our results showed that although FOB needs more time to check the position of DLT, it should be used to confirm the exact position of DLT.

A Two-Stage Bedside Intubation Method to Improve Success Rate of Post-pyloric Placement of Spiral Nasoenteric Tubes in Critically Ill Patients: A Multi-Center, Prospective Study.

BackgroundsProkinetic agents could improve the success rate of post-pyloric placement of self-propelled spiral nasoenteric tubes (NETs), and bedside blind technique might apply as a rescue therapy subsequent to spontaneous transpyloric migration failure. The objective of this study was to investigated the validity and safety of these two bedside intubation methods as a sequential procedure for post-pyloric placement of spiral NETs in critically ill patients.MethodsThe multicenter, prospective study was conducted in intensive care units of four tertiary hospitals (June 2020 to January 2021). Eligible patients received self-propelled spiral NET placements, promoted by prokinetic agents (Stage 1). An abdominal X-ray performed 24 h post-intubation confirmed the position of the tube tip. Patients with a failed transpyloric migration entered Stage 2, where beside blind intubation was conducted (reconfirmed by X-ray). The primary end point was the overall success rate of post-pyloric placement.ResultsThe overall success rate of post-pyloric placement of the spiral NET was 91.1% (73.4% in the third portion of the duodenum [D3] or beyond). The total adverse event rate was 21.0%, without any serious adverse events. In Stage 1, 55.6% of participants achieved transpyloric migration, of these, 44.4% migrated to D3 or beyond. The median time from decision to intubate to the initiation of enteral nutrition (EN) was 25 h. In Stage 2, 83.0% of patients had successful post-pyloric intubation (67.9% in D3 or beyond). The median time from decision to EN initiation after the two-stage process was 36 h.ConclusionsProkinetic agents-assisted self-propelled intubation and remedial bedside blind technique as a sequential procedure for post-pyloric placement of spiral NETs were effective and safe, and this two-stage process did not affect the implementation of early EN in critically ill patients.Trial RegistrationChinese Clinical Trial Registry, ChiCTR1900026381. Registered on 6 October 2019.

Comparison of blind and endoscopic-guided orotracheal intubation on laryngeal and tracheal damage in domestic rabbits (Oryctolagus cuniculus)

ObjectiveTo compare blind and endoscopic-guided techniques for orotracheal intubation in rabbits and the number of intubation attempts with laryngeal/tracheal damage. Study designProspective, randomized experimental study. AnimalsA total of 24 healthy, intact female New Zealand White rabbits, weighing 2.2 ± 0.2 kg (mean ± standard deviation). MethodsRabbits were randomly assigned to blind (group B) or endoscopic-guided (group E) orotracheal intubation with a 2.0 mm internal diameter uncuffed tube. Intramuscular (IM) alfaxalone (7 mg kg–1), hydromorphone (0.1 mg kg–1) and dexmedetomidine (0.005 mg kg–1) were administered, and additional IM alfaxalone (3–5 mg kg–1) and dexmedetomidine (0.025 mg kg–1) were administered to rabbits with strong jaw tone. An intubation attempt was defined as the advancement of the endotracheal tube from the incisors to the laryngeal entrance. Tracheal intubation was confirmed via capnography and anesthesia was maintained with isoflurane for 2 hours. Following euthanasia, laryngeal and tracheal tissues were submitted for histopathology. Quality of anesthesia for orotracheal intubation, intubation procedure and tissue damage were numerically scored. Data were analyzed using Poisson regression, Spearman’s correlation, t test, mixed anova, Mann–Whitney U test, Friedman and Chi square tests as appropriate. ResultsMedian (range) intubation attempts were 2 (1–8) and 1 (1–3) for groups B and E, respectively. More rabbits in group E (91.6%) required additional alfaxalone and dexmedetomidine than in group B (16.7%). Median (range) cumulative histopathology scores were 6 (3–10) and 6 (2–9) for groups B and E, respectively. Scores were highest in the cranial trachea, but there was no difference between groups and no correlation between laryngeal/tracheal damage and the number of intubation attempts. Conclusions and clinical relevanceBoth orotracheal intubation techniques were associated with laryngeal/tracheal damage. Although blind orotracheal intubation was associated with a higher number of attempts, the tissue damage was similar between groups.

3: Comparison of the blockbustertm and air-q®supraglottic airway devices as a conduit to blind endotracheal intubation in paediatric patients: a randomised controlled trial.

Background and Aims:There is scarcity of literature recommending the use of supraglottic airway devices (SADs) as conduits for blind endotracheal intubation. This study was conducted to compare the efficacy of two laryngeal mask airways (BlockbusterTMSAD and air-Q® SAD) in acting as a conduit for blind endotracheal intubation in paediatric patients undergoing non-emergency surgeries under general anaesthesia.Methods:In this randomised controlled trial, 80 paediatric patients with American Society of Anesthesiologists (ASA) physical status I and II, aged between 6 months and 10 years and weighing between 5 to 30 kg, were randomly allocated to two groups in which the airway was secured either with BlockbusterTMSAD or air-Q® SAD followed by blind endotracheal intubation. The primary outcome was the percentage of successful blind endotracheal intubation in a single attempt. The secondary outcomes were oropharyngeal leak pressure (OLP), insertion time, manipulations, perioperative complications.Results:Success rate of intubation with BlockbusterTMSAD was significantly higher (p value = 0.03) as compared to with air-Q® SAD ( 77.5% vs 55%). OLP was also significantly higher (p value = 0.001) with BlockbusterTM SAD (25.74 ± 7.05) cm H2O as compared to air-Q® SAD (15.2 ± 5.58) cm H2O. Complications were comparable in the groups.Conclusion:We found that both BlockbusterTM and air-Q® SAD have good success rate; however, Blockbuster success rate was significantly higher. Hence we conclude that BlockbusterTM is a better SAD for use as a conduit to blind endotracheal intubation in paediatric patients. It can reliably be used as a ventilatory device as well because of better OLP.VariableBlockbusterAir-Q P Successful31 (77.5%)22 (55%)0.033Unsuccessful9 (22.5%)18 (45%)OLP (cm H2O)25.74±7.0515.20±5.580.001

Abstract No.: ABS2070: Comparative evaluation of intubating Laryngeal Mask Airway (Fastrach) and Blockbuster Laryngeal Mask Airway for blind tracheal intubation in general surgical operations

Background & Aims:Supraglottic devices fill a niche between the facemask and tracheal tube. The aim of this study was to compare the insertion characteristics (ease of insertion), insertion time, number of attempts, haemodynamic changes and complications (if any)following blind tracheal intubation.Methods:The comparative study was conducted by dividing 70 patients of age 18-60 years, ASA grade I and II into two groups of 35 patients each who were scheduled for general surgical operations. Group F underwent blind tracheal intubation usingFastrach LMA whereas Group B underwent blind tracheal intubation using Blockbuster LMA. The two groups were thencompared for the efficacy and overall success rate of blind tracheal intubation in patients undergoing surgeries under general anaesthesia.Association of cough, vocal cord movement and patient’s reaction with groups Group D (DEXEM)Group P (PROPOFOL)Totalχ2, P No.%No.%No.%Cough None2893.32893.35693.3χ2=0.000, P=1.000 Slight26.726.746.7Vocal Cord Movement Open2583.32893.35388.3χ2=1.456, P=0.228 Moving516.726.7711.7Patient Reaction No reaction826.72066.72846.7χ2=10.410, P=0.015 Slight grimacing1033.36201626.7 Severe grimacing1136.7413.31525 Defensive movement of head, hands or feet13.30011.7 Total301003010060100 Comparison of Intubation Score among both Groups Group D Group P P Mean SD Mean SD Intubation Score4.41.33.61.00.007Results:Both devices were inserted in first attempt only. The first time successful ETT insertion following Blockbuster LMA was in 33/35 patients (94.29%) as compared to 26/35 patients (74.29%) of FT LMA. The mean time taken by Group B was13.57±3.48 seconds as compared to 18.82±5.09 seconds of Group F. The complications (sore throat, dysphagia, dysphonia) were significant for Group F as compared to Group B. The haemodynamic parameters were insignificant for both the groups.Group FGroup B No.% ageNo.% ageFirst time successYes2674.293394.29No925.7125.71Total35100.0035100.00Χ2: 5.285; P=0.002Conclusion:Although both supraglottic devices are feasible for blind tracheal intubation, Blockbuster LMA is a better option as it provides higher first pass success rate with less complications like sore throat, dysphagia and dysphonia.

COMPARATIVE EVALUATION OF LMA CTRACH VERSUS LMA FASTRACH FOR TRACHEAL INTUBATION

Introduction: TM The intubating laryngeal mask airway (ILMA) or LMA Fastrach was invented as a ventilatory device,and TM as a conduit for blind tracheal intubation. However, intubation through LMA Fastrach requires multiple attempts. LMA TM TM CTrach is a modification of LMA Fastrach and allows intubation under direct vision via an integrated fibreoptic bundle and a detachable liquid crystal display viewer.This study was undertaken to compare the first attempt success rate of TM tracheal intubation through the CTrach laryngeal mask and LMA Fastrach . Methods and Materials:This prospective randomized study was conducted on 100 adults,ASA physical status I and II patients of either sex, scheduled to undergo general anaesthesia requiring tracheal intubation for elective surgery.The patients were randomly allocated to two groups of 50 patients each, to be intubated via CTrach (GROUP CT, n=50) or ILMA (GROUP FT,n=50).The first-attempt and overall success rates of tracheal intubation,the times taken and incidence of pharyngo-laryngeal morbidity,were recorded. Results: Tracheal intubation was successful on the first attempt in 96% of patients with the LMA CTrach™ and 84% of patients with the LMA Fastrach™ (p= 0.045). The success rates within three attempts were 100% in both groups (p=0.124).The mean time taken for the complete tracheal intubation process was 109.6 ± 38.679 seconds with the LMA CTrach™ and 118.68 ±22.342 seconds with the LMA Fastrach™ (p= 0.154). Conclusion: To conclude, both airway devices are comparable and efficacious and the overall success of tracheal intubation was 100% in both groups.

Tracheal intubation using intubating laryngeal tube iLTS-D™ and LMA Fastrach™ in 99 adult patients: A prospective multicentric randomised non-inferiority study

Study objectiveThis study aimed to investigate the overall success of tracheal intubation using the intubating Laryngeal Tube Suction-Disposable (iLTS-D™, VBM, Sulz a. N., Germany) compared to the Laryngeal Mask Airway (LMA) Fastrach™ (Teleflex, Athlone, Ireland). We hypothesised that the iLTS-D™ would be non-inferior to the LMA Fastrach™ for tracheal intubation and ventilation. DesignMulticentric, non-inferiority, randomised controlled study. SettingOperating rooms from two tertiary and one secondary centre in Switzerland from January 2017 to July 2019. The investigators were trained anaesthetists with extensive experience with laryngeal masks but limited to laryngeal tubes. The study was discontinued after the planned interim analysis. PatientsNinety-nine adult patients were included after randomisation. The inclusion criteria were American Society of Anesthesiologists physical status 1 to 3 in patients scheduled for elective surgery requiring tracheal intubation. Patients with a history of difficult intubation were excluded. Intervention(s)After anaesthesia induction and once neuromuscular blockade was obtained, ventilation was initiated, and tracheal intubation was performed through the randomised device with the flexible endoscope tip placed proximally to the tip of the tracheal tube (visualised blind intubation). MeasurementsThe primary outcome was the intubation success rate after two attempts. The secondary outcomes were time to intubation, successful ventilation rate, time to achieve ventilation, and gastric access success rate. Main resultsThe overall intubation success rate was significantly higher in the Fastrach™ group than in the iLTS-D™ group (91.8% vs 70.0%, p = 0.006). No difference was found in the ventilation success rate (94% for iLTS-D™ and 100% for LMA Fastrach™ [p = 0.829]). The time to achieve ventilation and intubation were similar between the groups. No major airway complications were noted. ConclusionsAlthough both supraglottic devices provided the same effective ventilation rate, the LMA Fastrach™ was superior to the iLTS-D™ as a conduit for intubation in 99 adult patients without a known difficult intubation. These preliminary results need to be confirmed in studies that include a larger population.Trial registration:Clinicaltrials.gov, 21.09.2016, Identification Number NCT02922595.

Comparison between Polyvinyl Chloride and Flexometallic Endotracheal Tube for Blind Tracheal Intubation through I-gel: A Randomised Clinical Study

Introduction: I-gel is the most commonly used, secondgeneration supraglottic airway device, which plays an important role in modern anaesthesia practice as a rescue device in difficult as well as failed intubation situations and resuscitations. Now-a-days, it is gaining popularity as a conduit to facilitate endotracheal intubation. No Endotracheal Tube (ETT) is designed specifically for intubation through I-gel. The ETT used for routine tracheal intubation are standard Polyvinyl Chloride (PVC) ETT and Flexometalic ETT. Aim: To compare the two different types of ETTs i.e. standard PVC ETT and Flexometatlic ETT for blind tracheal intubation through I-gel. Materials and Methods: The present study was a singleblinded, randomised clinical trial in which 120 patients were randomly allocated into two groups on the basis of the ETT used for intubation through I-gel. In Group P blind tracheal intubation was done using PVC ETT, and in Group F blind tracheal intubation was done using Flexometatlic ETT through I-gel. Time taken for successful intubation, number of successful intubations, ease of intubation, number of attempts,manoeuvers used, and complications were recorded. Results: The mean time taken for successful intubation in Group P was 22.31±3.771 sec and in Group F was 26.51±4.408 sec (p<0.05). Intubation was significantly easy (26/60 vs 13/60) with PVC ETT (p=0.011). More patients were successfully intubated with PVC ETT than Flexometalic ETT (48/60 vs 36/60; p=0.017). Conclusion: PVC ETT is a better choice for blind tracheal intubation through I-gel as compared to flexometallic ETT.

Usefulness of lateral cephalometric radiography for successful blind nasal intubation: a prospective study.

This study aimed to investigate the relationship between pharyngeal morphology and the success or failure of blind nasotracheal intubation using standard lateral cephalometric radiography and to analyze the measurement items affecting the difficulty of blind nasotracheal intubation. Assuming a line perpendicular to the Frankfort horizontal (FH) plane, the reference point (O) was selected 1 cm above the posterior-most end of the hard palate. A line passing through the reference point and parallel to the FH plane is defined as the X-axis, and a line passing through the reference point and perpendicular to the X-axis is defined as the Y-axis. The shortest length between the tip of the uvula and posterior pharyngeal wall (AW), shortest length between the base of the tongue and posterior pharyngeal wall (BW), and width of the glottis (CW) were measured. The midpoints of the lines representing each width are defined as points A, B, and C, and the X and Y coordinates of each point are obtained (AX, BX, CX, AY, BY, and CY). For each measurement, a t-test was performed to compare the tracheal intubation success and failure groups. A binomial logistic regression analysis was performed using clinically relevant items. The items significantly affecting the success rate of blind nasotracheal intubation included the difference in X coordinates at points A and C (Odds ratio, 0.714; P-value, 0.024) and the ∠ABC (Odds ratio, 1.178; P-value, 0.016). Using binomial logistic regression analysis, we observed statistically significant differences in AX-CX and ∠ABC between the success group and the failure group.

Blind bougie first pass success endotracheal intubation process: An out-of-hospital case report

The blind bougie technique is performed when the epiglottis is visible to the intubator, but the vocal cords cannot be seen (Grade III Cormack-Lehane view). The blind bougie technique for endotracheal intubation is not routinely performed by Critical Care Paramedics for a failed intubation in the prehospital setting. However, at Hamad Medical Corporation Ambulance Service in the State of Qatar, the blind bougie technique is included in their failed airway clinical practice guidelines. This case report aims to describe the rapid sequence induction for intubation process and endotracheal tube placement in an adult trauma patient, presenting with a difficult airway, using the blind bougie technique in the out-of-hospital setting. A 35-year-old male patient was ejected from an all-terrain vehicle following a high-speed accident in the desert. The patient sustained an isolated head injury. Based on the patient’s clinical presentation, he required immediate endotracheal intubation for maintenance and protection of his airway prior to rapid transport to definitive care. Predictors of difficult airway were calculated. Using the blind bougie technique, endotracheal intubation was performed with first pass success. It is recommended that emergency medical services include the blind bougie technique of endotracheal intubation among their difficult airway procedures.

Success rate of endotracheal intubation: A comparison of direct laryngoscopy and intubating laryngeal mask airway

Context: Direct laryngoscopy (DL) remains the most popular method of endotracheal intubation despite the availability of easier methods like intubating laryngeal mask airway (ILMA)—a blind intubation aid with a high success rate of intubation even when employed by novices. Aim: This study compared the overall success rate of intubation using ILMA and DL during elective surgeries requiring intubation. Study Design: This was a comparative randomized study. Patients and Methods: Following the institutional ethical approval, 86 American Society of Anaesthesiologists physical status (ASA) I and II patients were randomized into DL and ILMA groups. Each received intravenous fentanyl 2 μg/kg, glycopyrrolate 4 μg/kg, intravenous propofol 3 mg/kg, suxamethonium 2 mg/kg to a maximum of 100 mg. Intubation was with DL in the first group and ILMA in the second group. Anesthesia was maintained with isoflurane and muscle relaxation with atracurium. The overall success rate, the success rate at the first attempt of intubation, time for intubation, and airway complications were assessed. Statistical analysis: Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 21.0. The quantitative variables were analyzed using the Student's t-test and qualitative using the Chi-square test. A P value less than 0.05 was considered significant. Results: The success at insertion was 100% in the DL group and 95.3% with ILMA at the first attempt (P = 0.15). The success rate of intubation at the first attempt was 100 and 79.1% in the DL and ILMA groups, respectively. The mean time for intubation was 19.93 ± 6.17 and 46.54 ± 11.63 s in DL and ILMA, respectively (P = 0.001). Six patients (14%) had airway complications in the ILMA group. Conclusion: The overall success rate of intubation via ILMA is comparable to that of DL. In patients with normal airways, DL remains a comparatively faster and easier technique to secure the airway with tracheal intubation than ILMA.

Improve the success rate of inserting and intubating the spiral nasojejunal tube with bare hands

[Objective] To improve the success rate of spiral nasojejunal tube insertion through training of blind insertion of spiral nasojejunal tube with bare hands. [Methods] A total of 49 patients (5 of them were secondary intubation) who were admitted to the emergency department of our hospital from April 2, 2019 to June 17, 2021 needed to undergo blind hand intubation treatment with a nasal jejunal tube. The nurses who were recruited to participate in Guangdong. The enteral nutrition intubation training class hosted by the Provincial Nursing Society Critical Care Committee has been divided into two groups: the experimental group after training (n=28) and the control group before training (n=21) at the aim of comparing the success rate of one-time catheterization of patients in the two groups. [Results] The success rate of nurses' bare-handed blind insertion of the nasal jejunal tube increased from 43% to 86% (p<0.01). [Conclusion] Carrying out the training of blind insertion of nasal jejunal tube with bare hands can improve the success rate of tube placement for nurses in emergency department.

A study to compare Air-Q intubating laryngeal airway with Ambu Auragain laryngeal mask for blind tracheal intubation using Parker flex tip tube.

Background and Aims:A number of supraglottic airways have been developed to facilitate the passage of tracheal tubes. Various studies have been conducted using air-Q ILA as a conduit for endotracheal intubation. Ambu AuraGain is a newer 3rd generation supraglottic airway device. There are limited studies available in literature on blind tracheal intubation through the Ambu AuraGain. This study was designed to compare air-Q ILA and Ambu AuraGain as conduit for blind tracheal intubation using Parker flex tip tube.Material and Methods:One hundred twenty patients of either sex, aged 18-60 years, belonging to ASA physical status I or II scheduled for elective surgery under general anesthesia requiring endotracheal intubation were included in the study. Patients were randomly allocated to one of the two groups. Group A (n = 60) included blind intubation through air-Q ILA using Parker flex tip tube and group B (n = 60) included blind intubation through Ambu AuraGain using Parker flex tip tube.Results:The first attempt success rate was significantly more in group A (P < 0.001). Intubation was significantly easy in group A as compared to group B (P < 0.001). The mean time for insertion of endotracheal tube through air-Q ILA in group A was 17.85 ± 6.25 sec while in group B it was 30.19 ± 10.97 sec (P < 0.001).Conclusion:Air-Q ILA resulted in significantly more success rate and ease of intubation as compared to Ambu AuraGain.

Clinical study of temporomandibular joint ankylosis &amp; its management

Introduction: TMJ ankylosis is one of the problem at OGH and a challenge both to the Anesthesiologist and the surgeon. Aim: To study the etiology, occurrence in relation to age, sex, side and severity & choice of management of Temporomandibular joint Ankylosis and their outcome. Methodology: This is a study of the cases, which numbered about 15 cases, has been operated in the Department of Plastic Surgery at Osmania General Hospital between 2011 to 2015 and 2017 to 2018 in association with department of Radiology and department of Oral Medicine . The Epidemiology, Causes and Management of Temporomandibular Joint Ankylosis and Outcome are studied in all patients. All these patients had clinical and radiological evidence of bony ankylosis with minimal inter incisor distance pre-operatively. Results: In the present study, the age of presentation in this study was between 10 and 35 years with commonest age being second decade. In this study TMJ Ankylosis was common in females. (female: male=2:1). Childhood trauma was the major cause. Unilateral involvement was more common (5:1) and frequently on left side. Most of the patients presented to the hospital when the mouth opening dropped below 0.5 cm. All the patients were intubated successfully with awake blind nasal intubation. All the patients were routinely extubated when patient was stable. In this study Acrylic ball interpositional arthroplasty in adults was the procedure of choice with no major complications. Average mouth opening achieved in this study was 36mm. Early postoperative physiotherapy with molar bite blocks & active chewing exercises and follow-up is mandatory to prevent recurrence. No recurrence was noticed in this study group. Conclusion: The primary objective of adequate mouth opening which is long lasting is achieved in this series.

Comparative evaluation of Intubating Laryngeal Mask Airway (ILMA), I-gel and Ambu AuraGain for blind tracheal intubation in adults.

Background and Aims:The supraglottic airway devices (SADs) that allow direct (without an intermediary device like Aintree or airway exchange catheters) tracheal intubation can be invaluable for field use in conditions ideally managed by intubation. Whilst fiberscope-guided intubation is the method of choice, if these ‘direct-intubation’ SADs could provide high success rates for blind tracheal intubation, their scope of use can increase tremendously. Our study assesses intubating laryngeal mask airway (ILMA), i-gel and Ambu AuraGain for blind tracheal intubation in adults.Material and Methods:Ninety adults undergoing elective surgery were randomized into three equal groups. After induction of anesthesia, the group-specific SAD was inserted and on achieving adequate ventilation, blind tracheal intubation was attempted over two attempts. Success rates and time of achieving adequate device placement and tracheal intubation through these were evaluated. Data were analyzed using SPSS version 17.0 and P < 0.05 was considered statistically significant.Results:All three devices could achieve adequate ventilation within two allowed attempts. Successful tracheal intubation rates were significantly better with ILMA than i-gel on first attempt (87% vs. 27%, P < 0.001) and after second attempt that was supplemented with optimization maneuvers (100% vs. 40%, P < 0.001). No patient could be intubated through Ambu AuraGain within two attempts. Time taken for successful tracheal intubation did not differ significantly (P = 0.205) with ILMA or i-gel.Conclusion:Out of ILMA, I-gel and Ambu AuraGain, ILMA is the best device for blind tracheal intubation in adults with normal airways.

Blind nasal intubation in a 'breathing' manikin- An idea.

Blind nasal intubation (BNI) has been around for over a century now. Many clinicians advocate it as an “old-is-gold” skill, which can be performed without any adjuncts in cases where visualization of larynx is a problem. Even today, BNI not only comes handy in resource-limited centers, it may also come to the rescue of airway managers in well-equipped centers. However, in the century since it was first described, there have been other major developments in the field of airway management and BNI as a skill has taken a backseat when it comes to a priority order. More so because it is limited by modalities to teach and train as most of the available manikins, which are otherwise phenomenal when it comes to imitating anatomy and overall attention to detail of a human airway, suffer terribly in one basic aspect needed to teach, train, and learn BNI—”they” cannot breathe! Attempts have been made to fabricate some manikins on these lines. But what if they can not only breathe but breathe out CO2 as well! We describe a simple method whereby we created a “CO2 breathing” manikin and tested it in an Airway Management Workshop with 105 participants, and then evaluated it under controlled conditions in 20 volunteers. We got very encouraging results and realized that our manikin makes the teaching and training of BNI very interesting and attractive by simulating the actual clinical scenario. We feel that it has the potential of reinventing the valuable skill of BNI.