Case Of Difficult Intubation Research Articles

Comparison of Modified Mallampati Classification in Supine and Sitting Positions to Predict Difficult Tracheal Intubation in Diabetic Patients.

Airway management of patients with long-standing diabetes poses a major challenge for anaesthesiologists due to stiff joint syndrome affecting the atlanto-occipital joint. In certain cases requiring immobilization, the Mallampati test must often be performed in the supine position for obvious reasons. Hence, we determined the diagnostic precision (sensitivity and specificity) of the modified Mallampati test in sitting and supine positions among the diabetic population in predicting difficult tracheal intubation. A single-center prospective observational study on adult diabetic patients undergoing general anesthesia and orotracheal intubation was carried out. An observer recorded the modified Mallampati in the sitting posture during the pre-anesthetic examination. The Mallampati in the supine position was determined while in the operating room, and the difficulty of intubation was noted, and diagnostic precision was calculated. The main objective was to predict a difficult airway by calculating the sensitivity, specificity, positive predictive value, and negative predictive value. Out of the 150 participants, Mallampati grading in a sitting position was correctly able to identify 42.5% of difficult intubation cases, whereas it was 97.5% with Mallampati in the supine position. Mallampati grading in the sitting position was able to correctly identify 89.1% of easy intubation cases, which was 63.6% with Mallampati in the supine position. The correlation of Mallampati in the supine position with CL grading was statistically significant (P < 0.001). Among diabetic patients, the modified Mallampati test in the supine position can be considered a more accurate and sensitive predictor of difficult intubation than the sitting posture.

Safety and efficacy of remifentanil target-controlled infusion for conscious sedation in a pregnant woman: a case report

BackgroundEvery year 2% of pregnant women undergo nonobstetric surgical interventions worldwide. According to the American College of Obstetricians and Gynecologists Committee on Obstetric Practice, pregnant women should never be denied the most appropriate surgical treatment, regardless of the trimester of pregnancy. However, additional attention should be paid during the first trimester since it has the highest risk of inducing teratogenic mutations; additionally, during the third trimester, due to the possibility of preterm birth and low birth weight of the newborn, great care should be paid.Case presentationWe present the case of a Caucasian 36-year-old woman during her 21st week of pregnancy, with a normal-sized fetus, according to the gestational age on ultrasound exam, and with no additional risk factors. The patient referred to an increasing nasal obstruction associated with rhinorrhea of the left nasal cavity. She also reported episodes of sleep apnea and hyposmia. The patient received a detailed otolaryngological examination, which allowed for identification of a mass within the left nasal cavity. The subsequent nasal endoscopy confirmed a grayish polypoid mass lesion with a multinodular surface occupying the entire left nasal fossa. The lesion totally obliterated the left maxillary sinus, resulting in obstruction of the anterior osteomeatal unit and ethmoidal sinusitis. She was referred for a functional endoscopic sinus surgery using analgosedation with remifentanil target-controlled infusion.Discussion and conclusionTo the very best of our knowledge, this is the first case described in English literature about the use of analgosedation with remifentanil target-controlled infusion for otolaryngology surgery, specifically in functional endoscopic sinus surgery. It could be an interesting option to avoid the use of inhaled anesthetics that could induce fetal damage, especially during the first months of pregnancy. Furthermore, patient intubation is not necessary, which avoids cases of difficult intubation or any trauma to the airways. An adequate informed consent and appropriate compliance are elements of paramount importance in tailoring the anesthetic strategy for pregnant women who need nonobstetric surgical management.

Cricothyrotomy - In Unanticipated Difficult Intubation Cases with Respiratory Compromise.

Introduction Cricothyrotomy, percutaneous dilation tracheostomy, and tracheostomy are all cost-effective and safe techniques used in the management of critically ill patients who need an artificial airway other than endotracheal tube ventilation. The present study focused on enlightening on elective and emergency procedures performed on conditions present with difficult airways and also attempts to shed light on the aspects of securing an airway in anticipated and unanticipated difficult intubation. Objective The objective of the study was to compare the three procedures conducted during difficult airway/failed intubation situations. Methods The present retrospective observational study was conducted collecting data from patient files obtained at a tertiary healthcare center from 2013 to 2018. The difficult intubation cases were managed by ear, nose, and throat (ENT) surgeons. The study compared three methods: Cricothyrotomy, percutaneous dilation tracheostomy, and tracheostomy based on factors such as procedure duration, complications, and the instruments required for each procedure. Results The study enrolled 85 patients, 61 males and 24 females, aged between 30 and 70 years old. To perform cricothyrotomy, only a simple blade was required. Cricothyrotomy had the shortest operating time (4.1±3.1 minutes) and the shortest time of full oxygen saturation (3 min). Percutaneous tracheostomy had the least amount of bleeding (1%). Cricothyrotomy significantly showed the least intraoperative bleeding than percutaneous dilation, tracheostomy, and tracheostomy ( p = 0.001). Conclusion Cricothyrotomy is preferable as it takes less time to perform, causes less bleeding, and takes the least time for full oxygen saturation than tracheostomy and percutaneous dilatational tracheostomy in "can't intubate, can't oxygenate" patients.

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

ObjectiveThe objective of our study was to compare the degree of difficulty and complications related to tracheal intubation in an Intensive Care Unit (ICU) before and after the introduction of an intubation protocol based on the Difficult Airway Society guidelines for the management of tracheal intubation in critically ill adults, published in 2018. MethodsProspective, observational study comparing all intubations performed in our ICU over 2 periods: pre-protocol (January 2015–January 2019) and post-protocol (February 2019–July 2022). The material used for intubation, the degree of difficulty, and intubation-related complications were recorded. ResultsDuring the study period, 661 patients were intubated - 437 in the pre-protocol period (96% by direct laryngoscopy) and 224 in the post-protocol period (53% with direct laryngoscopy, 46% with video laryngoscopy). We observed an improvement in laryngeal view in the post-protocol period compared to the pre-protocol period (Cormack–Lehane ≥ 2b in 7.6% vs. 29.8%, p < 0.001), and a decrease in the number of moderate-to-severely difficult intubations (6.7% vs. 17.4%, p < 0.001). The first-pass success rate was 92.8% in the post-protocol period compared to 90.2% pre-protocol (p = 0.508). We did not find significant differences in complications between the periods studied. ConclusionsIntubations performed in the post-protocol period were associated with improved laryngeal view and fewer cases of difficult intubation compared with the pre-protocol period.

Complicaciones y grado de dificultad de la intubación orotraqueal en la unidad de cuidados intensivos pre-post instauración de un protocolo de intubación para el paciente crítico. Estudio prospectivo y observacional

ObjectiveThe objective of our study was to compare the degree of difficulty and complications related to tracheal intubation in an intensive care unit (ICU) before and after the introduction of an intubation protocol based on the Difficult Airway Society guidelines for the management of tracheal intubation in critically ill adults, published in 2018. MethodsProspective, observational study comparing all intubations performed in our ICU over two periods: pre-protocol (January 2015-January 2019) and post-protocol (February 2019-July 2022). The material used for intubation, the degree of difficulty, and intubation-related complications were recorded. ResultsDuring the study period, 661 patients were intubated —437 in the pre-protocol period (96% by direct laryngoscopy) and 224 in the post-protocol period (53% with direct laryngoscopy, 46% with video laryngoscopy). We observed an improvement in laryngeal view in the post-protocol period compared to the pre-protocol period (Cormack-Lehane ≥2b in 7.6% vs 29.8%, P<.001), and a decrease in the number of moderate-to-severely difficult intubations (6.7% vs 17.4%, P<.001). The first-pass success rate was 92.8% in the post-protocol period compared to 90.2% pre-protocol (P=.508). We did not find significant differences in complications between the periods studied. ConclusionsIntubations performed in the post-protocol period were associated with improved laryngeal view and fewer cases of difficult intubation compared with the pre-protocol period.

Prediction of difficult laryngoscopy / difficult intubation cases using upper airway ultrasound measurements in emergency department: a prospective observational study

IntroductionDifficult laryngoscopy and intubation are serious problems among critically ill patients in emergency department (ED) so utility of a rapid, accurate and noninvasive method for predicting of these patients are necessary. Ultrasonography has been recently used in this regard and this study was conducted to investigate the correlation of some introduced upper airway ultrasound parameters with difficult laryngoscopy / difficult intubation in patients referred to the ED.MethodIn this prospective observational study all patients ≥ 18-year-old who had an indication for rapid sequence intubation (RSI) were included. Ultrasound parameters including Hyoid Bone Visibility (HBV), Distance from Skin to Hyoid Bone (DSHB), Distance from Skin to Vocal Cords (DSVC), Distance from Skin to Thyroid Isthmus (DSTI), and Distance between Arytenoids Cartilages (DBAC) were measured in all cases. The patients underwent RSI and thereafter the patients’ baseline characteristics, Cormack-Lehane grade, number of attempted laryngoscopy were recorded in a pre-prepared check list and compared with measured ultrasound parameters. The “difficult laryngoscopy” was defined as Cormack-Lehane classification grades III/IV; and need for more than 3 intubation attempts was considered as “difficult intubation”.ResultsOne hundred and twenty-three patients (52% male) were included of whom 10 patients (8.1%) were categorized as difficult laryngoscopy cases; and just 4 (3.3%) cases underwent more than 3 laryngoscopy attempts who considered as difficult intubation cases. The mean age of the patients in non-difficult and difficult intubation groups were 69.2 ± 15.16 and 68.77 ± 17.37 years, respectively (p > 0.05). There was no significant relationship between difficult laryngoscopy and HBV (p = 0.381) but has significant correlation with difficult intubation (p = 0.004). The DSHB had a significant correlation with difficult laryngoscopy (p = 0.002) but its correlation with difficult intubation was not significant (p = 0.629). The DSVC and DSTI had a significant relationship with both difficult laryngoscopy (p = 0.003 and p = 0.001), and difficult intubation (p = 0.025 and p = 0.001). The DBAC had not significant correlation neither with the difficult laryngoscopy (p = 0.142), nor with difficult intubation (p = 0.526).ConclusionThe findings showed that ultrasound parameters including soft tissue DSHB, DSVC and DSTI could be proper predictors of difficult laryngoscopy. Also, HBV, DSVC and DSTI may be proper predictors for difficult intubation. But DBAC was not useful in this regard.

Measurement of Neck Circumference, Tongue thickness and Skin to Epiglottis Distance as Predictors of Difficult Intubation: A Prospective Study

Airway Assessment is essential in pre anesthetic assessment. Anticipating and preparing for difficulty in airway management is crucial to avoid airway catastrophes. Routine pre operative airway examination usually includes mouth opening and dentition, Mallampati classification, thyromental distance and neck movements. Neck circumference is a quick bedside test to determine difficult laryngoscopy. Increased tongue thickness and skin to epiglottis distance affects performance of laryngoscopy and tracheal intubation increasing the risk of difficult airway. Presently there is a search for non-invasive and accurate tools to overcome limitations of clinical airway assessment tests. Ultrasonography has been evolving as a useful device for airway assessment especially soft tissue structures in anterior surface of neck. Here we studied the measurement of neck circumference and ultrasound measurement of tonguethickness and skin to epiglottis distance as predictors for difficult intubation. The Aim of the study is to predict difficulty in intubation by measuring neck circumference, thickness of tongue and thickness of skin to epiglottis. Prospective observational study, 120 patients posted for surgery under general anesthesia, Department of anesthesia, Meenakshi medical college, Kanchipuram. After institutional Human ethical committee clearance, 120 Patients were screened during preoperative assessment for undergoing procedures under general anaesthesia. Neck circumference and other airway parameters were measured with measuring tape and distance between Skin to epiglottis and tongue thickness were measured with ultrasound linear probe. Patients were grouped into Group E( Easy Intubation) whose Cormack-lehane grade was 1 and 2 and Group D ( Difficult intubation) whose Cormack-lehane grade was 3 and 4. SPSS version 16 was used for statistical analysis. There was no statistical significance seen between age, sex, height among easy and difficult intubation but significance was seen with weight (p &lt;0.05), Thyromental distance(p&lt;0.05) and Sterno-mental distance(p&lt;0.05). High significance was seen in Distance between skin to epiglottis distance(p&lt;0.001), Tongue thickness(p&lt;0.001) and Neck Circumference(p&lt;0.001) in difficult intubation cases. Neck circumference and ultrasonographic measurement of tongue thickness and skin to epiglottis can avoid unanticipated difficult intubation.

A Comparison of the Effectiveness of Videolaryngoscopy and Macintosh Laryngoscopy in Intubation Attempts on Adult Patients.

This study aimed to compare the effectiveness of videolaryngoscopy and Macintosh laryngoscopy on adult patients who were scheduled for elective surgery under general anaesthesia. Of the 200 adult patients who were scheduled to undergo general anaesthesia, 100 were intubated with a videolaryngoscope and 100 with a Macintosh laryngoscope. The patients' age, sex, American Society of Anesthesiologists score, height, weight, body mass index, smoking and alcohol habits, comorbidity, and neck circumference were recorded. Their El-Ganzouri Risk Index score, which considers the parameters of mouth opening, thyromental distance, Mallampati score, neck movement, propensity for prognathism, body weight, and history of difficult intubation, was also calculated and recorded. The time to achieve intubation was then recorded. The number of intubation attempts, number of cases of difficult intubation, Cormack-Lehane scores, and incidences of trauma or complication were also evaluated. The mean intubation time was found to be significantly lower in the videolaryngoscope group compared to the Macintosh laryngoscope group. Although the number of patients with difficult intubation was high in the videolaryngoscope group, when we evaluated their glottic view, the Cormack-Lehane score was found to be significantly lower. The number and ratio of complications due to intubation were lower in the videolaryngoscope group compared to the Macintosh laryngoscopy group. In patients undergoing endotracheal intubation for general anaesthesia, it was concluded that videolaryngoscopy is superior to Macintosh laryngoscopy as it enlarges the glottic view, shortens the time to achieve intubation, facilitates intubation, and has less risk of complications.

Usefulness of preoperative computed tomography findings for airway management in patients with acute odontogenic infection: a retrospective study.

Odontogenic infection is more likely to affect the airway and interfere with intubation than non-odontogenic causes. Although anesthesiologists predict the difficulty of intubation and determine the method, they may encounter unexpected cases of difficult intubation. An inappropriate intubation can cause airway obstruction due to bleeding and edema by damaging the pharynx and larynx. This study was performed to determine the most important imaging findings indicating preoperative selection of an appropriate intubation method. This retrospective study included 113 patients who underwent anti-inflammatory treatment for odontogenic infection. The patients were divided into two groups according to the intubation method: a Macintosh laryngoscope (45 patients) and others (video laryngoscope and fiberscope) (68 patients). The extent of inflammation in each causative tooth, the severity of inflammation (S1-4), and their influence on the airway were evaluated by computed tomography. The causative teeth were mandibular molars in more than 90%. As the severity of inflammation increased, anesthesiologists tended to choose intubation methods other than Macintosh laryngoscopy. In the most severe cases (S4), anesthesiologists significantly preferred other intubation methods (33 cases) over Macintosh laryngoscopy (9 cases). All patients with S4 showed inflammation in the parapharyngeal space, and the airway was affected in 41 patients. The mandibular molars were the causative teeth most likely to affect the airway and surrounding region. In addition to clinical findings, the presence or absence of inflammation that has spread to the parapharyngeal space on preoperative computed tomography was considered an important indicator of the difficulty of intubation.

Predictive Value of Modified Mallampati Test and Upper Lip Bite Test Concerning Cormack and Lehane's Laryngoscopy Grading in the Anticipation of Difficult Intubation: A Cross-Sectional Study at a Tertiary Care Hospital, Bhubaneswar, India.

Background and objectiveMany tests are at hand to predict difficult intubation preoperatively to prevent morbidity and mortality of unanticipated difficult intubation. The present study was conducted to evaluate and compare the efficacy of the modified Mallampati test (MMT) and upper lip bite test (ULBT) to foresee difficult intubation.Materials and methodsAfter obtaining written informed consent, this prospective comparative observational study was conducted on 225 patients scheduled for elective surgery under general endotracheal anesthesia. Preoperative MMT and ULBT were performed. MMT Grade III, IV, and ULBT Grade IV were regarded as predictors of difficult intubation. The laryngoscopic view was graded as per Cormack and Lehane's laryngoscopic grading after induction of anesthesia by an experienced anesthesiologist ignorant of preoperative airway evaluation. Patients with Cormack and Lehane Class III and IV were regarded as difficult intubation. Sensitivity, specificity, and positive and negative predictive values of MMT and ULBT were computed. Agreement between two tests with the Cormack Lehane test was determined by the Kappa coefficient.ResultsIn our research, the occurrence of difficult intubation was found to be 10.2% (23 cases of difficult intubation out of 225 patients). In our analysis, we found the sensitivity (95.5% vs. 95.4%), specificity (54.8% vs 50.0%), positive predictive value (91.6% vs 93.1%), and negative predictive value (39.1% vs 39.1%) were almost comparable between modified Mallampati test and upper lip bite test. Kappa coefficient for the upper lip bite test (0.492) was slightly higher as compared to modified Mallampati scoring (0.454), but both the values are highly statistically significant (p-value <0.001).ConclusionBoth the upper lip bite test and modified Mallampati test are comparable with each other and since the upper lip bite test is easy to perform bedside test we recommend it to be used alone or in collaboration with other tests in assessing difficult airways.

Frequency and Risk Factors for Difficult Intubation in Women Undergoing General Anesthesia for Cesarean Delivery: A Multicenter Retrospective Cohort Analysis.

Estimates for the incidence of difficult intubation in the obstetric population vary widely, although previous studies reporting rates of difficult intubation in obstetrics are older and limited by smaller samples. The goals of this study were to provide a contemporary estimate of the frequency of difficult and failed intubation in women undergoing general anesthesia for cesarean delivery and to elucidate risk factors for difficult intubation in women undergoing general anesthesia for cesarean delivery. This is a multicenter, retrospective cohort study utilizing the Multicenter Perioperative Outcomes Group database. The study population included women aged 15 to 44 yr undergoing general anesthesia for cesarean delivery between 2004 and 2019 at 1 of 45 medical centers. Coprimary outcomes included the frequencies of difficult and failed intubation. Difficult intubation was defined as Cormack-Lehane view of 3 or greater, three or more intubation attempts, rescue fiberoptic intubation, rescue supraglottic airway, or surgical airway. Failed intubation was defined as any attempt at intubation without successful endotracheal tube placement. The rates of difficult and failed intubation were assessed. Several patient demographic, anatomical, and obstetric factors were evaluated for potential associations with difficult intubation. This study identified 14,748 cases of cesarean delivery performed under general anesthesia. There were 295 cases of difficult intubation, with a frequency of 1:49 (95% CI, 1:55 to 1:44; n = 14,531). There were 18 cases of failed intubation, with a frequency of 1:808 (95% CI, 1:1,276 to 1:511; n = 14,537). Factors with the highest point estimates for the odds of difficult intubation included increased body mass index, Mallampati score III or IV, small hyoid-to-mentum distance, limited jaw protrusion, limited mouth opening, and cervical spine limitations. In this large, multicenter, contemporary study of more than 14,000 general anesthetics for cesarean delivery, an overall risk of difficult intubation of 1:49 and a risk of failed intubation of 1:808 were observed. Most risk factors for difficult intubation were nonobstetric in nature. These data demonstrate that difficult intubation in obstetrics remains an ongoing concern.

A Two-operator Approach For Tracheal Intubation: The Techniques

Based on the review of literature on tracheal intubation procedure for general anesthesia in elective surgery, it can be concluded that a combined approach using tools for the glottic region and trachea visualization allows the tube insertion and placement under visual guidance, which resolves a majority of difficult intubation cases. A two-operator approach for tracheal intubation could resolve the challenge, while the development of the perfect intubation tool is awaited.

Management of difficult and failed intubation in the general surgical population: a historical cohort study in a tertiary care centre.

The objective of this study was to describe the incidence, management, and complications of difficult and failed endotracheal intubation in a general surgical population. This historical cohort study included all cases of difficult endotracheal intubation in general surgical patients at Mount Sinai Hospital (Toronto, ON, Canada) from 1 January 2011 to 31 December 2017. Patient charts and electronic records were reviewed to collect data on airway management and complications. Endotracheal intubation was graded as "difficult" if more than two attempts with direct laryngoscopy or if additional equipment for second or subsequent attempts was required, and "failed" if it could not be achieved despite the attempts. The primary outcome was the incidence of difficult and failed intubation. The secondary outcomes were complications, difficult airway parameters, mask ventilation, number of intubation attempts, and rescue devices including the eventually successful method. We identified 111 cases of difficult intubation (0.26%) and 14 cases of failed intubation (0.03%) in 42,805 surgical cases requiring endotracheal intubation over the seven-year period. The incidence was highest in 2012 (0.36%) and lowest in 2017 (0.13%). Difficulty was anticipated in 84 (76%) patients. The median (range) number of intubation attempts was 2 (2-5). Videolaryngoscopy was the eventually successful method in those with unsuccessful first attempt direct laryngoscopy (n = 91) and videolaryngoscopy (n = 17) in 71% and 77% cases, respectively. Intubation failed in 14 patients, three of whom required a surgical airway because the lungs could not be ventilated. Poor visualization of the glottis (93%) and airway bleeding (36%) were the leading causes of failed intubation. Desaturation was seen in 8%, airway bleeding in 7%, and airway edema in 6% of cases of difficult intubation. The incidences of difficult and failed intubations in our study were 2.6 and 0.3 per 1,000 surgeries requiring laryngoscopies, respectively, with a decrease over time. Videolaryngoscopy showed a high success rate as a rescue device.

Comparison of the intubation success rate between the intubating catheter and videolaryngoscope in difficult airways: a prospective randomized trial

BackgroundSeveral devices and algorithms have already been examined and compared for difficult airway management. However, there is no existing study comparing the success of the Intubating Catheter (IC) and the Videolaryngoscope (VL) in patients who are difficult to intubate. We aimed to compare Frova IC and McGrath VL in terms of intubation success rates in patients with difficult intubation. MethodsThis prospective, randomized study was performed in an university hospital. Patients who underwent an operation under general anesthesia and whom airway management process was deemed difficult were included in this study. Patients were randomly divided into two groups by envelopes containing a number: the intubating catheter group (Group IC), intubated using the Frova IC, and the videolaryngoscope group (Group VL), intubated using the McGrath VL. Study data were collected by a technician who was blind to the study groups and the type of device used in the intubation procedure. ResultsA total of 49 patients with difficult airway were included in the study, including 25 patients in the Frova IC Group and 24 patients in the McGrath VL Group. The rate of successful intubation was determined to be 88% in Group IC and 66% in Group VL (p = 0.074). The mean duration of intubation attempt in Group VL was 44.62 seconds, whereas in Group IC, it was 51.12 seconds (p = 0.593). Group VL was found to have a significantly lower Cormack-Lehane grade compared to Group IC (p < 0.001). ConclusionFrova IC is a candidate to be an indispensable instrument in terms of cost-effectiveness in clinics such as anesthesia and emergency medicine, where difficult intubation cases are frequently encountered. However, the combination of Frova IC and McGrath VL seems to be more successful in difficult intubation situations, so future studies should focus on using these two devices together.

The impact of introducing a videolaryngoscope in the initial training of laryngoscopy for undergraduate medical students: a simulation randomized trial

IntroductionAdequate and continuous airway management by health professionals is fundamental to ensure patient safety and protection. Among several techniques, laryngoscopy for orotracheal intubation is considered a basic skill, so it is taught and learned in medical school and used during the future years of professional practice. However, in some clinical scenarios, physical and anatomical characteristics can make laryngoscopy exceedingly difficult. In the last decade, some new devices have emerged to apply indirect or video-assisted imaging systems, so-called videolaryngoscopes. They have shown great efficiency in difficult intubation cases and have improved teaching and training. Our study introduced a videolaryngoscope, the McGrath... MAC, in the regular laryngoscopy training rotation for 3rd-year undergraduate medical students and evaluated whether there was any associated optimization of the students... performance. MethodStudents from two different classes and years (2017 and 2018) were randomly divided into two groups and received theoretical and practical training in the techniques of Direct Laryngoscopy (DL) and Videolaryngoscopy (VL). The students in each group applied the manoeuvres and simulated three tracheal intubation attempts on mannequins. They were evaluated for their success rate on the first attempt, the time required to finalize the intubation, and the visualization of the glottic structures according to the classification of Cormack-Lehane (C&L). ResultsTwo hundred and four students with an average age of 21.ß...ß2 years participated in the study; the groups were similar. There was a significant difference between the VL and DL groups in the 1st attempt success rate (97% and 89.4%, respectively, p.ß=.ß0.0497 ... 95% CI), but such a difference was not seen for the other attempts or regarding the number of oesophageal intubations (3% and 7.7%). The students in the VL group were faster than those in the DL group in all intubation attempts; in parallel, the vast majority of the VL group reported excellent visualization conditions, with 75% of the attempts classified as Cormack-Lehane grade 1. ConclusionThe introduction of a videolaryngoscope in medical students... training improved the visualization of anatomical structures and allowed tracheal intubation maneuvers to be performed faster and with a higher success rate on the first attempt. Thus, under the conditions of this prospective study, the videolaryngoscope had a positive impact on training and proved to be a promising tool for teaching laryngoscopy.

Superior Laryngeal Nerve Block for Intubation in Patients With COVID-19.

Coronaviruses are thought to primarily spread via respiratory droplets and close or direct contact. Transmission is also possible through prolonged exposure to high concentrations of virally infected aerosols in a relatively closed environment.1 Once generated, these aerosols reportedly remain suspended in the air for up to 3 hours.2 Certain clinical procedures such as intubation and extubation are particularly known to generate potentially contagious aerosols that could infect medical personnel.3 Canelli et al4 recently invented an “aerosol box,” a barrier that can be easily fabricated, to reduce the risk of viral transmission and infection via exposure to contaminated aerosols for clinicians performing intubation- and extubation-related procedures. This barrier consists of a transparent plastic cube that encases the patient's head, with 2 circular ports through which clinicians can insert their hands to manage the airway with minimal exposure. However, this box restricts hand mobility and requires prior training before use in actual clinical procedures.5Ponnappan et al6 analyzed their preliminary experience using the aerosol box during 30 endotracheal intubations performed by anesthesiologists at the Institute of Liver and Biliary Sciences, New Delhi. The mean experience of the anesthesiologists involved in that study was 5.3 years after completion of anesthesia training. Successful intubation was achieved in 38.1% of cases during the first attempt. A second attempt was required in 28.6% of cases, and removal of the aerosol box was required in 28.6% of cases because of poor vision and/or inadequate space to facilitate proper airway management. In difficult intubation cases in which it was necessary to intubate while spontaneous ventilation was maintained, success rates while using the aerosol box would have likely decreased significantly.Reducing coughing during intubation could contribute to a reduction in viral transmission and exposure among health care workers. Coughing can be reduced by several techniques such as the administration of nebulized lidocaine to anesthetize the airway or intravenous boluses of opioid agonists for cough suppression, among others. In our hospital, we use moderate sedation with midazolam and fentanyl for patients with suspected difficult intubation or airway management. Once the patient is adequately sedated, a bilateral superior laryngeal nerve (SLN) block (SLNB) can be performed to further reduce coughing during intubation, because the block effectively prevents contraction of the cricothyroid muscle. The block can be performed percutaneously without ultrasound guidance (Figure). Therefore, even when the need for emergent intubation unexpectedly becomes apparent, it can be performed relatively easily and quickly. The SLN provides sensation to the upper part of the larynx (and lower part of the pharynx).7–10 SLNB has been used to facilitate awake endotracheal intubations during endoscopic laryngeal surgeries.11,12 Alessandri et al13 reported that SLNB reduced cough and discomfort during awake fiber-optic intubations. However, this block can be associated with potential complications, including intravascular injection and nerve damage. Nevertheless, we believe that cough suppression via bilateral SLNB can be a useful approach for reducing aerosol generation during airway management (ie, intubation). It must be mentioned that appropriate personal protective equipment still remains necessary for adequate protection at all times, particularly during this pandemic.We do not have any experience intubating patients infected with SARS-CoV-2, the virus that causes the novel coronavirus disease 2019 (COVID-19). However, we are of the opinion that SLNB is likely to be effective in reducing coughing and aerosol generation during difficult airway management in patients with COVID-19.

Retrospective Evaluation of Pediatric Difficult Intubation Cases in terms of Otorhinolaryngology

Retrospective Evaluation of Pediatric Difficult Intubation Cases in terms of Otorhinolaryngology

Unusual way of securing the airway using gastroscope and cystoscope as an alternative to fiberoptic intubation

Difficult airway still is one of the dreaded crises in anesthesia. A well-formulated plan with all the necessary equipment should be ready when such situations are anticipated, but unanticipated difficulties can arise, and managing such cases is a nightmare for the anesthesiologist. Most hospitals in the developing countries are not equipped technically with all the modern equipment and gadgets as far as anesthesia is concerned. In a resource-constrained area, the skill and innovative ideas of the anesthesiologist often emerge as an alternative option in dealing with such cases. Here, we describe two cases of difficult intubation by conventional approach, which were managed successfully using a pediatric gastroscope and a flexible cystoscope as an alternative to fiberoptic bronchoscope.

Video Laryngoscopic Endotracheal Intubation in Cardiac Operation Theater - Experience at a Peripheral Tertiary Healthcare Centre of Bangladesh

Background: Endotracheal intubation is an essential primary skill for all anesthesiologists. For cardiac anesthesiologists rapid and proper intubation is more important as failure may cause serious consequences. Video laryngoscope provides a better real time view of the larynx, epiglottis and vocal cords. It also keeps the intubating anesthetist away from the patient as compared to conventional laryngoscopy. This may be very important in this COVID-19 era. To the best of our knowledge the Department of Cardiac Surgery and Cardiac Anesthesia of Chattogram Medical College &amp; Hospital is the first center in Bangladesh to introduce video laryngoscope in cardiac OT.&#x0D; The objective of this study was aimed to compare the intubation time, hemodynamic response to laryngoscopy, success rates and operator’s comfort using the conventional Macintosh laryngoscope and video laryngoscope in adult patients undergoing cardiac surgery.&#x0D; Materials and Methods: A total of 60 adult patients were included in this comparative study, subjected to general anesthesia for cardiac surgery, intubated using either conventional Macintosh direct laryngoscope or video laryngoscope. Patients were intubated by 3 different consultant anesthesiologists with equal competency of our department.&#x0D; Results: There was not much difference between Video laryngoscopy and conventional laryngoscopy in terms of intubation time and success rate. Video laryngoscopy exhibited less hemodynamic response to laryngoscopy and intubation; however, the difference was not statistically significant in this small group of patients. Operators were much more comfortable with Video laryngoscope than conventional laryngoscope particularly with the cases of difficult intubation because of the better glottic view with the former.&#x0D; Conclusion: Video laryngoscope is preferred by cardiac anesthetists because of better glottic view.&#x0D; Bangladesh Heart Journal 2020; 35(1) : 47-53

An innovative approach to the intubation of cervical lipomas: Taking the easy way in!

The use of videolaryngoscopes for difficult intubation as an adjunct has been established in the various international airway guidelines. However, planning a case of difficult intubation mandates the use of proper positioning in order that the intubation is successful and atraumatic. Various methods to facilitate proper positioning have been described that include the use of bolsters, preformed pillows, and ramps. The trials faced by anesthetists who attempt to successfully negotiate the difficult airway posed by cervical lipomas consist of difficulty faced during positioning for intubation, need for additional need for workforce during positioning, and the need to transfer an intubated, anesthetized patient for surgery while facing the risk of accidental disconnection and extubation. This case series describes an innovative method of positioning to assist intubation that requires no additional equipment, reduces the chances of accidents during positioning, and in conjunction with the use of videolaryngoscope simplifies a difficult airway procedure.