Conventional Endotracheal Intubation Research Articles

More efficient endoscopic submucosal dissection with deep endotracheal intubation for superficial cervical esophageal carcinoma: a dual-center, prospective, randomized controlled study

Deep endotracheal intubation (DET) has been proposed to improve cervical esophageal endoscopic submucosal dissection (ESD) because of the limited space and visibility. We aimed to evaluate the efficacy and safety of DET. In the current dual-center trial, patients were randomized into DET or conventional endotracheal intubation (CET) groups. Complete resection rate, operation time, and adverse events were measured and compared. Fifty-nine patients (60 lesions) were assigned to the groups, showing comparable baseline characteristics. The complete resection rates were similarly high in both groups. However, DET significantly reduced ESD operation time (52.2 minutes vs 71.1 minutes, P< .001) and postoperative pain scores (3.1 vs 4.7, P< .01). Severe stenosis occurred more frequently in the CET patients (20% vs 0%, P= .035). No significant differences were observed in other adverse events. DET can overcome technical challenges to improve therapeutic efficiency and safety. (Clinical trial registration number: NCT06420258.).

Submental intubation in patients with maxillofacial fractures: case report and literature review

Background: Conventional orotracheal and nasotracheal intubation can be challenging in patients requiring fixation of fractures of the maxillofacial skeleton. The proximity of the surgical site for maxillofacial procedures to the airway predisposes patients with maxillofacial pathologies to anaesthetic complications like dislodged endotracheal (ET) tubes and inadvertent extubation. The need for maxillomandibular fixation (MMF) as part of fracture management precludes the use of orotracheal intubation. In patients with nasal bone fractures, nasotracheal intubation may not be feasible, and the complications associated with tracheostomy make it a last resort for securing access to the airway. The purpose of this article is to highlight the usefulness of submental intubation in the management of patients with maxillofacial fractures.Case presentation: We present our initial experience with the submental route of intubation and illustrate the procedure with a case of a patient with midface fractures successfully managed using submental intubation. A literature review of alternative airway routes to conventional orotracheal and nasotracheal intubation is also included.Discussion: Edentulous spaces, retromolar intubation, submental intubation, submandibular intubation, and tracheostomy have been used as alternatives to conventional endotracheal intubation. Each route has its associated advantages, disadvantages, and limitations.The submental approach is fast, easy to learn, and associated with minimal complications.Conclusion:Submental intubation is a safe option for airway management in patients with maxillofacial fractures.

Micropipette tip intubation in rats as a replacement for conventional endotracheal tube intubation.

Endotracheal intubation is often necessary in the course of animal experiments, especially in craniofacial surgery. However, endotracheal intubation can be a major burden in this context. The authors performed simple and cost-saving method using a 200 μL yellow micropipette tip, and the success of this method was demonstrated by X-ray and autopsy. We used a total of 30 rats. After the rats were fixed with a plaster, the trachea and vocal cords were visualized with the tongue pulled back. Under direct visualization of the vocal cords, a curving micropipette tip was advanced into the trachea. This method can be learned quickly and applied successfully by general experimenters. We successfully intubated all 30 rats without any complications. The success rate of micropipette tip intubation was 100%. This procedure was performed by one experimenter within 2 to 3 minutes after induction of anesthesia. We demonstrated its superiority by X-ray and autopsy. Herein, we describe endotracheal intubation of rats using micropipette tips. To the best of our knowledge, this method is novel and represents the simplest and most efficient means of intubation in rats, providing an alternative to conventional endotracheal intubation.

Multi-centre randomised trial of invasive and less invasive surfactant delivery methods showed similar spirometry results at 5-9 years of age.

We explored whether subnormal forced expiratory volume within 1 s (FEV1 ) at 5-9 years of age was lower in children born preterm who received less invasive surfactant administration (LISA) rather than surfactant via an endotracheal tube. The multi-centre, randomised Nonintubated Surfactant Application trial enrolled 211 preterm infants born at 23-26 weeks of gestation from 13 level III neonatal intensive care units from April 2009 to March 2012. They received surfactant via LISA (n=107) or after conventional endotracheal intubation (n=104). The follow-up assessments were carried out by a single team blinded to the group assignments. The main outcome was FEV1 < 80% of predicted values. Spirometry was successful in 102/121 children. The other children died or were lost to follow-up. Median FEV1 was 93% (interquartile range 80%-113%) of predicted values in the LISA group and 86% (interquartile range 77-102%) in the control group (p=0.685). Rates of FEV1 < 80% were 11/57 (19%) and 15/45 (33%), respectively, which was an absolute risk reduction of 14% (95% confidence interval -3.1% to 31.2%, p=0.235). There were no differences in other outcome measures. The proportion of children aged 5-9 years with subnormal FEV1 was not significantly different between the groups.

Evaluation of gum elastic bougie guided Proseal laryngeal mask airway insertion technique

Introduction: Endotracheal Intubation (ETI) is highest quality level for airway organization. LMA ProSeal™ (PLMA) insertion utilizing Gum Elastic Bougie (GEB) guidance, which has got 100% first attempt success rate, also requires laryngoscopy, hence nullifying its advantage of being a supraglottic airway device. We aimed to compare the hemodynamic responses associated with laryngoscopy assisted GEB guided PLMA placement with that of conventional endotracheal intubation. Method: Hundred normotensive ASA1 or 2 patients of either sex (age 18 to 40yrs) undergoing general anesthesia for elective surgery included and evaluated for pressor response. Following a uniform premedication and standard anesthesia technique (thiopentone + vecuronium), either of airway was placed and pulse rate, (beats/min); Mean blood pressure, MAP (mmHg) (at Tb = base line, T0 = just before laryngoscopy and PLMA/ETT placement, T1 = 1min, T3 = 3min, T5 = 5 min, T7 = 7 min after placement). Results: Patients demographics between the PLMA and ETT groups were similar. Following laryngoscopy and PLMA\ETT placement, both were associated with statistically significant increase in HR and MAP with respect to its basal value. Although it was less marked in case of PLMA Group, when comparison was made within individual Group. Duration of laryngoscopy and time of placement were longer in PLMA Group as compared to ETT Group (35.71 and 12.69 sec. vs 21.30 and 10.76 sec. respectively). ETT insertion was related with higher incidence of cough (p 0.05). Conclusion: Hence GEB guided PLMA method must be used as a reinforcement method in cases where standard insertion methods fall ineffective and in ineffectual tracheal intubation where the bougie is incidentally embedded into throat and quick control of the airway route is essential. Key words: Gum elastic bougie; Laryngeal Mask Airway; Hemodynamics; Pressor response Abbreviations: LMA – laryngeal mask airway; ETI – Endotracheal Intubation; GEB – Gum Elastic Bougie; ETT –Endotracheal tube; PLMA – Laryngeal Mask Airway ProSeal Citation: Upadhyay MK, Kumar G, Chaurasia A, Narang D. Evaluation of gum elastic bougie guided Proseal laryngeal mask airway insertion technique. Anaesth. pain intensive care 2021;25(3):338–344. DOI: doi.org/10.35975/apic.v25i3.1531 Received: March 20, 2021; Reviewed: April 11, 2021; Accepted: May 11, 2021

Comparison of the Effects of Endotracheal Intubation of Wistar Rats Using the Conventional Technique vs. a New Modified Technique Using a 3D Mouth-Piece

Aims Endotracheal intubation in rats is challenging due to the difficult anatomical characteristics of the airway. The success rate at first attempt is low and airway damage is a common complication. We aimed to compare and evaluate the conventional intubation method with a modified procedure using an inclined plate, headlamp (700-Lumen), and 3D mouth-piece designed with a 20° curvature. Both techniques were conducted by laboratory personnel with and without previous experience in airway management of laboratory rats. Material and methods In this study, we used 36 Wistar rats of both genders. Three groups of laboratory personnel (anesthesiologists, medical students, and laboratory technicians) performed both endotracheal intubation techniques, i.e., blind intubation at supine position and endotracheal intubation at 70° supine position with a 3D mouth-piece and direct illumination of the glottis. Results The modified technique had a significantly higher success rate and shorter procedure duration. Moreover, there was no significant difference in the procedure duration between personnel with and without previous training in airway management. Conclusion Previous knowledge and experience in airway management are required when performing conventional endotracheal intubation; moreover, its success rate is low. Contrastingly, using proper instruments and the 3D mouth-piece facilitated easier and quicker airway management regardless of previous experience.

Advanced airway management success rates in a national cohort of emergency medical services agencies

ObjectiveDespite its important role in care of the critically ill, there have been few large-scale descriptions of the epidemiology of Emergency Medical Services (EMS) advanced airway management (AAM) and the variations in care with different patient subsets. We sought to characterize AAM performance in a national cohort of EMS agencies. MethodsWe used data from ESO Solutions, Inc., a national EMS electronic health record system. We analyzed EMS emergency patient encounters during 2011–2015 with attempted AAM. We categorized AAM techniques as conventional endotracheal intubation (cETI), neuromuscular blockade assisted intubation (NMBA-ETI), supraglottic airway (SGA), and cricothyroidotomy (needle and open). Determination of successful AAM was based on EMS provider report. We analyzed the data using descriptive statistics, determining the incidence and clinical characteristics of AAM cases. We determined success rates for each AAM technique, stratifying by the subsets cardiac arrest, medical non-arrest, trauma, and pediatrics (age ≤12 years). ResultsAAM occurred in 57,209 patients. Overall AAM success was 89.1% (95% CI: 88.8–89.3%) across all patients and techniques. Intubation success rates varied by technique; cETI (n = 38,004; 76.9%, 95% CI: 76.5–77.3%), NMBA-ETI (n = 6768; 89.7%, 88.9–90.4%). SGAs were used both for initial (n = 9461, 90.1% success, 95% CI: 89.5–90.7%) and rescue (n = 5994, 87.3% success, 95% CI: 86.4–88.1%) AAM. Cricothyroidotomy success rates were low: initial cricothyroidotomy (n = 202, 17.3% success, 95% CI: 12.4–23.3%), rescue cricothyroidotomy (n = 85, 52.9% success, 95% CI: 41.8–88%). AAM success rates varied by patient subset: cardiac arrest (n = 35,782; 91.7%, 95% CI: 91.4–92.0), medical non-arrest (n = 17,086; 84.7%, 84.2–85.2%); trauma (n = 4341; 84.3%, 83.1–85.3%); pediatric (n = 1223; 73.7%, 71.2–76.2%). ConclusionAAM success rates varied by airway technique and patient subset. In this national cohort, these results offer perspectives of EMS AAM practices.

Predictive performance of a multivariable difficult intubation model for obese patients.

BackgroundA predictive model of scores of difficult intubation (DI) may help physicians screen for airway difficulty to reduce morbidity and mortality in obese patients. The present study aimed to set up and evaluate the predictive performance of a newly developed, practical, multivariate DI model for obese patients.MethodsA prospective multi-center study was undertaken on adults with a body mass index (BMI) of 30 kg/m2 or more who were undergoing conventional endotracheal intubation. The BMI and 10 preoperative airway tests (namely, malformation of the teeth in the upper jaw, the modified Mallampati test [MMT], the upper lip bite test, neck mobility testing, the neck circumference [NC], the length of the neck, the interincisor gap, the hyomental distance, the thyromental distance [TM] and the sternomental distance) were examined. A DI was defined as one with an intubation difficulty scale (IDS) score ≥ 5.ResultsThe 1,015 patients recruited for the study had a mean BMI of 34.2 (standard deviation: 4.3 kg/m2). The proportions for easy intubation, slight DI and DI were 81%, 15.8% and 3.2%, respectively. Drawing on the results of a multivariate analysis, clinically meaningful variables related to obesity (namely, BMI, MMT, and the ratio of NC to TM) were used to build a predictive model for DI. Nevertheless, the best model only had a fair predictive performance. The area under the receiver operating characteristic curve (AUC) was 0.71 (95% confidence interval 0.68–0.84).ConclusionsThe predictive performance of the selected model showed limited benefit for preoperative screening to predict DI among obese patients.

Performance and skill retention of five supraglottic airway devices for the pediatric difficult airway in a manikin

Supraglottic airway devices (SADs) have been introduced to assist medical professionals in emergency situations with limited experience in securing airways via conventional endotracheal intubation (ETI). Literature on the use of SADs for securing an airway during pediatric critical settings is scarce, and there is a lack of studies comparing different SADs to each other and to conventional ETI. We conducted a study comparing five different SADs to ETI with regard to success rate, time to first ventilation, and personal rating in a pediatric manikin under simulated physiologic and pathologic airway conditions in 41 pediatricians of varying clinical experience and training. Only the AirQ, AuraG, and laryngeal tube (LT) were inserted within 30 s correctly by all participants under physiologic conditions. In tongue edema (TE), AirQ and LT had the highest success rate. In limited mobility of the cervical spine (CS), AirQ, AuraG, and LT again all were inserted within 30 s. In a multivariate analysis, factors influencing the success were experience with the respective device and level of medical education. Under TE conditions, there were significantly longer insertion times for the ETI, laryngeal mask airway (LMA), and EzT. Under CS conditions, there were significantly longer insertion times for the ETI, LMA, LT, and EzT. A multivariate analysis showed experience with the respective device to be the only factor of influence on time to first ventilation.Conclusion: LT, AuraG, and AirQ were superior in providing fast and effective ventilation during simulated difficult airway situations in pediatricians.What is Known:• Supraglottic airway devices have been introduced for medical professionals who lack experience for managing difficult airway situations.• A variety of these devices have been developed so far, but not compared to each other yet.What is New:• We compared five different supraglottic airway devices with regard to success rate, time to first ventilation, and personal rating in a pediatric manikin under simulated physiologic and pathologic airway conditions.• Laryngeal tube, AuraG, and AirQ were superior in providing fast and effective ventilation during simulated difficult airway situations in pediatricians with varying clinical experience.

Effects of transcutaneous electrical acupoint stimulation on quality of recovery during early period after laparoscopic cholecystectomy

To evaluate the effect of transcutaneous electrical acupoint stimulation (TEAS) on the quality of recovery during the early period after laparoscopic cholecystectomy and the dosage of anesthetic and analgesic. One hundred patients who received laparoscopic cholecystectomy with gradeⅠand Ⅱ of American Society of Anesthesiologists (ASA) criteria were randomly assigned into an observation group and a control group according to random number table, 50 cases in each group. The patients in the two groups were treated with conventional endotracheal intubation anesthesia, anesthesia induction and maintenance. The patients in the observation group were treated with TEAS (2 Hz/100 Hz, 8 to 12 mA) at bilateral Hegu (LI 4) and Neiguan (PC 6), as well as Zusanli (ST 36) and the non-acupoint 2 cun outboard from Zusanli (ST 36) from 30 min before anesthesia induction to the end of operation. The patients in the control group were applied by stimulation electrode in the corresponding points without electrical stimulation. The dosage of intraoperative remifentanil and the analgesic dosage of dezocine for postoperation were recorded. The recovery time, extubation time, the changes of heart rate (HR) and mean arterial pressure (MAP) during extubation were recorded. The quality of recovery was assessed by the quality of recovery-40 questionnaire (QoR-40) 1 day before surgery (T0)，and 4 h (T1), 8 h (T2), 24 h (T3), 48 h (T4) after surgery. The patient's cognitive function was assessed by mini-mental state examination (MMSE) scale at the 5 time points. The incidences of postoperative nausea and vomiting were recorded at T1 through T4. The dosages of intraoperative remifentanil and dezocine in the observation group were less than those in the control group; the recovery time and extubation time were shorter than those in the control group; the HR of extubation was lower than that in the control group (all P<0.05). There was no statistic difference about MAP between the two groups (P>0.05). Compared with T0, the total scores of QoR-40 decreased in the two groups at T1, T2, T3 (all P<0.05), and the total scores in the observation group were higher than those in the control group (all P<0.05). The emotional state, physical comfort, psychological support, self-care ability, pain scores at T1 in the observation group and at T1, T2, T3 in the control group were lower than those at T0 (all P<0.05). The emotional state, physical comfort, psychological support, self-care ability, pain scores in the observation group were higher than those in the control group at T1, T2, T3 (all P<0.05). Compared with T0, the MMSE scores in the two groups decreased at T1 and T2 (all P<0.05). At T1, T2, T3, the MMSE scores in the observation group were higher than those in the control group (all P<0.05). At T1 and T2, the incidence rates of nausea and vomiting were 22.0% (11/50), 12.0% (6/50) respectively in the observation group, which were lower than 32.0% (16/50) and 24.0% (12/50) in the control group (both P<0.05). At T3 and T4, the incidence rates of nausea and vomiting were 6.0% (3/50), 2.0% (1/50) respectively in the observation group, which were not significantly different from 8.0% (4/50) and 4.0% (2/50) in the control group (both P>0.05). TEAS can improve the quality of recovery during the early period after laparoscopic cholecystectomy and reduce the dosage of anesthetic and analgesic.

Inclusion of the Acute Care Surgeon in the Difficult Airway Protocol: A Nine-Year Experience

An emergency surgical airway is a lifesaving intervention required in the event of airway loss or respiratory failure when conventional endotracheal intubation cannot be performed. The Acute Care Surgery/Trauma Service is a critical component in the angioedema/difficult airway protocol at our institution. We conducted a retrospective review (2007-2016) to analyze the role our service has in managing patients requiring an emergency surgical airway. Cases were analyzed for preexisting conditions, hospital location of procedure, techniques, complications, and mortality. Our protocol involves early coordination between anesthesia and the Acute Care Surgery/Trauma Service for patients with a potentially difficult airway. If anesthesia is unable to intubate the patient, a surgical airway is performed. Patients are preemptively taken to the operating room (OR) if stable for transport. There were 43 surgical airways performed during the study period. All patients had a failed attempt with oral endotracheal intubation. The most common factors associated with these patients were history of tracheostomy, angioedema, or difficult anatomy. Nineteen (44%) of the surgical airways were performed in the OR. Three deaths (7%) occurred from cardiac or respiratory arrest despite the emergency procedure. No immediate deaths occurred in the patients taken to the OR. Early coordination in patients with a difficult airway is another hospital resource that the acute care surgeon can provide to improve patient outcomes.

Direct laryngoscopy using video-laryngoscope for endo-tracheal intubation in the Emergency Department: An educational and patient safety initiative

Background: Conventional endotracheal intubation (ETI) is challenging and requires high level of individual skills and experience. At the same time we are also committed to provide ETI training for Emergency Medicine Residents (EMR). Video laryngoscope (VDL) like the C-MAC (by Karl Storz) is designed to have a similar blade to the normal Macintosh blades (size 3 and 4). It has a bright light source and blade thickness that allow Direct Laryngoscopy (DL) and hence ETI under direct vision. We organised several sessions of ETI training using an intubating manikin. We found that the view from the C-MAC screen captured by the C-MAC video camera is the same view described by the operator doing the DL. There were enough consistencies reported during several training sessions that we decided to use the C-MAC for DL in real cases of ETI in the resuscitation room. We have done several ‘live’ cases and all intubations successfully as DL, with the added benefit of ‘video supervision’ and ‘video confirmation’ of the tube positioning. We also used the video recording and playback functions to give feedback to the EMR at the end of the procedure. Methods (Case Report): In this educational poster, we describe a step-by-step laryngoscopic and ETI view seen on the C-MAC screen during one of our airway training session with the manikin. We also include several views of possible poor technique in laryngoscopy that may result in a failed intubation attempt. Results: We discuss the potential safety and training benefits in conventional ETI using C-MAC VDL. Conclusion: We conclude that promoting the use of this technique in ED, especially for ETI undertaken by a trainee improves patient safety and supervision.

A validation study of the intubation difficulty scale for obese patients

Study objectiveAn intubation difficulty scale (IDS) is the most commonly used tool to pronounce difficult intubation among obese patients in research area. There have not been any studies on assessing the use of IDS. The objectives were to determine the performance of the IDS among obese patients to define difficult tracheal intubation (DI) according to the subjective assessment of the difficulty experienced and to identify their optimal cutoff points. DesignCross-sectional study. SettingTertiary care hospital. PatientsAdult obese Thai patients who underwent conventional endotracheal intubation. MeasurementsData of subjective assessment of the difficulty experienced by category—easy, somewhat difficult, and difficult—were collected from experienced anesthetic personnel who performed endotracheal intubation. IDS scores were collected by research assistants. Main resultsThere were 552 obese patients recruited. The incidence of somewhat DI was 14.3% and that of DI was 2.2%. The overall performance of the IDS using area under the receiver operating characteristic curves of somewhat DI is 0.99 with 95% confidence interval (CI) of 0.98 and 0.99 and that of DI is 1 (95% confidence interval, 1-1). For somewhat DI, the optimal cutoff point is 2; it provides sensitivity and specificity of 100% and 92%. The IDS scores of 5 indicate DI which had sensitivity and specificity of 100% and 100%. ConclusionsThe IDS remains a good tool to declare DI among obese patients. It is recommended that a score of 2 or higher is an optimal cutoff point to indicate somewhat DI and a score of 5 or higher is an optimal cutoff point to indicate DI.

A prospective, randomised, cross-over trial comparing two standard polyvinyl chloride tracheal tubes. Are all the tubes the same?

BackgroundA randomised study was conducted on the number of attempts made during the conventional endotracheal intubation of a mannequin using two polyvinyl (PVC) tracheal tubes, apparently similar but from different manufactures: Intersurgical (IS; Intersurgical S.L., Madrid, Spain) and Mallinckrodt (ML; Mallinkrodt Medical S.A., Madrid, Spain). MethodsA total of 26 anaesthesiologists, in randomly established order (generated by Epidat 3.1) intubated a mannequin twice using a different tube each time. The tubes were masked by painting them to prevent recognition. The main outcome of the study was to compare the number of attempts needed to complete the manoeuvre for each tube. Data on intubation time and failed intubations were also collected. ResultsThe number of attempts with the ML tube was significantly lower than with the IS tube. Intubation was completed on the first attempt with the ML tube in 93.3% of cases, while using the IS tube the percentage fell to 30.8% (Fisher exact test, p<0.001). The time required to complete the manoeuvre was greater with the IS tube (median 10.8s, interquartile range 6–22) than with the ML tube (median 4.4s, interquartile range 3.5–6.3). ConclusionsThe PVC tube from the ML manufacturer was superior when compared with the IS, the latter was also associated with a larger number of attempts to complete intubation using a conventional Macintosh blade.

The effect of a standardised source of divided attention in airway management: A randomised, crossover, interventional manikin study.

Dual-tasking, the need to divide attention between concurrent tasks, causes a severe increase in workload in emergency situations and yet there is no standardised training simulation scenario for this key difficulty. We introduced and validated a quantifiable source of divided attention and investigated its effects on performance and workload in airway management. A randomised, crossover, interventional simulation study. Center for Training and Simulation, Department of Anaesthesiology, Erlangen University Hospital, Germany. One hundred and fifty volunteer medical students, paramedics and anaesthesiologists of all levels of training. Participants secured the airway of a manikin using a supraglottic airway, conventional endotracheal intubation and video-assisted endotracheal intubation with and without the Paced Auditory Serial Addition Test (PASAT), which served as a quantifiable source of divided attention. Primary endpoint was the time for the completion of each airway task. Secondary endpoints were the number of procedural mistakes made and the perceived workload as measured by the National Aeronautics and Space Administration's task load index (NASA-TLX). This is a six-dimensional questionnaire, which assesses the perception of demands, performance and frustration with respect to a task on a scale of 0 to 100. All 150 participants completed the tests. Volunteers perceived our test to be challenging (99%) and the experience of stress and distraction true to an emergency situation (80%), but still fair (98%) and entertaining (95%). The negative effects of divided attention were reproducible in participants of all levels of expertise. Time consumption and perceived workload increased and almost half the participants make procedural mistakes under divided attention. The supraglottic airway technique was least affected by divided attention. The scenario was effective for simulation training involving divided attention in acute care medicine. The significant effects on performance and perceived workload demonstrate the validity of the model, which was also characterised by high acceptability, technical simplicity and a novel degree of standardisation.

Estudio prospectivo, aleatorizado y cruzado que compara 2 tubos endotraqueales de polivinilo. ¿Son todos los tubos iguales?

BackgroundA randomised study was conducted on the number of attempts made during the conventional endotracheal intubation of a mannequin using two polyvinyl (PVC) tracheal tubes, apparently similar but from different manufactures: INTERSURGICAL (IS; Intersurgical S.L., Madrid, Spain) and Mallinckrodt (ML; Mallinkrodt Medical S.A., Madrid, Spain). MethodsA total of 26 anaesthesiologists, in randomly established order (generated by Epidat 3.1) intubated a mannequin twice using a different tube each time. The tubes were masked by painting them to prevent recognition. The main outcome of the study was to compare the number of attempts needed to complete the manoeuvre for each tube. Data on intubation time and failed intubations were also collected. ResultsThe number of attempts with the ML tube was significantly lower than with the IS tube. Intubation was completed on the first attempt with the ML tube in 93.3% of cases, while using the IS tube the percentage fell to 30.8% (Fisher exact test, P<.001). The time required to complete the manoeuvre was greater with the IS tube (median 10.8seconds, interquartile range 6-22) than with the ML tube (median 4.4seconds, interquartile range 3.5 to 6.3). ConclusionsThe PVC tube from the ML manufacturer was superior when compared with the IS, the latter was also associated with a larger number of attempts to complete intubation using a conventional Macintosh blade.

Influence of propofol and isoflurane on insulin resistance and proinflammatory cytokines

Objective To investigate the influence of propofol and isoflurane on insulin resistance and proinflammatory cytokines.Methods 42 patients underwent abdominal surgery were randomly divided into group A and group B.All cases were given conventional endotracheal intubation anesthesia.Group A (21 cases) was given propofol anesthesia,group B (21 cases) was given isoflurane.The levels of glucose (Glu),insulin (IN),interleukin-6 (IL-6) and tumor necrosis factor alpha(TNF) were detected before anesthesia,2h after anesthesia and postoperative 24h.Insulin sensitive index(ISI) and insulin resistance index(IRI) were calculated.All data were analyzed.Results 2h after anesthesia,Glu level of group B was obviously increased compared with before anesthesia(P ＜ 0.05).But it of group A was slightly increased (P ＞ 0.05).Postoperative 24h,Glu level of the two groups was obviously increased compared with before anesthesia (P ＜ 0.05).2h after anesthesia and postoperative 24h,IN,IRI,IL-6 and TNFαdevels of the two groups were obviously higher than before anesthesia(P ＜ 0.05).ISI level of the two groups was obviously lower than before anesthesia (P ＜ 0.05).2h after anesthesia,IRI,IL-6 and TNFα levels of group B were obviously higher than those of group A,and ISI level was obviously lower than group A (P ＜ 0.05).Conclusion Compared with isoflurane,propofol anesthesia can lessen stress reaction and insulin resistance caused by surgical trauma to some extent.But both propofol and isoflurane can not completely relieve stress reaction and insulin resistance Key words: Anesthesia; Propofol; Isoflurane; Insulin resistance; Proinflammatory cytokines

Comparison of the Airtraq and the Macintosh laryngoscope for double-lumen tube intubation

The Airtraq is a disposable optical laryngoscope that is available in a double-lumen tube version. Inserting a double-lumen tube is generally more difficult compared to conventional endotracheal intubation, mainly due to its configuration. The aim of this study was to compare the Airtraq with the Macintosh laryngoscope for intubation with a double-lumen tube in patients undergoing elective thoracic surgery. The main outcome was time needed for successful intubation. Prospective, randomised clinical trial. A single centre, University Hospital of Würzburg, Germany, between July 2009 and June 2011. After a scout laryngoscopy with a Macintosh laryngoscope, 60 adult patients were intubated by an anaesthesiologist with either an Airtraq (n = 30) or a Macintosh laryngoscope (n = 30). The time needed for correct intubation, checked by flexible bronchoscopy, was recorded. The intubation difficulty scale (IDS) and Cormack and Lehane grade were noted. Haemodynamic variables and any evidence of oropharyngeal trauma were documented as well as postoperative sore throat, hoarseness and dysphagia. The mean time needed for correct intubation was 20.1 ± 16.5 s in the Airtraq group and 17.5 ± 10 s in the Macintosh group (P = 0.86). All intubations in both groups had an IDS less than 4. The Cormack and Lehane grade was I in all 30 patients in the Airtraq group; in the Macintosh group, it was I and II in 17 and 13 patients, respectively. The incidence of hoarseness was significantly higher in the Airtraq group 24 h postoperatively (P = 0.01). There was no significant difference between the Airtraq and the Macintosh laryngoscopes regarding the time needed to insert a double-lumen tube during elective thoracic surgery. Only subtle enhancement of visualisation and a higher incidence of hoarseness were observed in the Airtraq group. The Airtraq device did not result in superior patient safety in this setting.

Laryngeal morbidity after tracheal intubation: the Endoflex® tube compared to conventional endotracheal intubation with stylet

Tracheal intubation may cause vocal fold damage. The trial was designed to assess laryngeal morbidity comparing the Endoflex(®) tube with a conventional endotracheal tube with stylet. We hypothesised that laryngeal morbidity within the first 24 h after extubation would be lower with the Endoflex tube than with the conventional endotracheal tube with stylet because of less rigidity. This randomised trial included 130 elective surgical patients scheduled for general anaesthesia with endotracheal intubation. Pre- and post-operative assessment of hoarseness, vocal fold pathology, and voice analysis using the Multidimensional Voice Program was performed. Induction of anaesthesia was standardised. After complete neuromuscular paralysis, intubation was done with an Endoflex tube or a conventional endotracheal tube with stylet. Post-operative hoarseness was found in 45% with the Endoflex tube and 55% with the endotracheal tube with stylet at 24 h after extubation (P = 0.44). Post-operative vocal fold injury was present in 23% in the Endoflex tube group and in 36% in the endotracheal tube with stylet group (P = 0.13). The increase in shimmer, the voice analysis variable reflecting vocal fold oedema, was 0.5% in the Endoflex tube group and 2.5% in the endotracheal tube with stylet group (P = 0.02). No significant difference was found in the incidence of hoarseness or vocal fold injury using the Endoflex tube. However, the statistically significant lower increase in the shimmer values in that group implies that the Endoflex may be associated with less laryngeal morbidity.

Direct endotracheal intubation using a novel detachable optic probe (Sunscope) by emergency medical technicians with various training backgrounds

ObjectiveEffective airway management requires both proper technique and the appropriate devices. With the widespread implementation of advanced life-support techniques in emergency medical services (EMS), orotracheal intubation is now performed not only by professional practitioners but, in many occasions, nonprofessionals. With extensively diversified skill equipped, we tested whether the Sunscope, a patented tracheal intubation device with a digital display, is able to facilitate tracheal intubation by naïve EMS personnel with various training backgrounds. MethodsWe conducted a study to determine rate of success and time required to insert an orotracheal tube into a mannequin using Sunscope. The participants were placed into the professional group (i.e., anesthesiologists and emergency medical paramedics; EMT-P) or the nonprofessional group (i.e., emergency medical technicians; EMT). Intubation required three steps: equipment preparation, vocal cord exposure, and tube insertion. The time required for each step was recorded by a senior staff member, and the data were analyzed by nonparametric statistics. ResultsEach consecutive step in the operating procedure was significantly shorter for the professional group in comparison with the nonprofessional group during the first trial: equipment preparation, 10.5 ± 2.1 vs. 11.9 ± 4.1 seconds; vocal cord exposure, 7.4 ± 7.7 vs. 12.2 ± 7.7 seconds; tube insertion, 8.8 ± 4.8 vs. 17.6 ± 9.4 seconds; and total time required for intubation, 26.7 ± 8.8 vs. 35.8 ± 19.6 seconds. The professional practitioners showed no significant improvement, in terms of time reduction, on the following three trials. On the other hand, the nonprofessional practitioners showed no significant differences, in terms of time required to expose the vocal cords and total operation time, following the third trial in comparison with the professional practitioners. ConclusionOur research demonstrates that professional practitioners are able to use the Sunscope on their first attempt. Despite a lack of training in conventional endotracheal intubation, emergency medical technicians (EMT-I and -II) were able to complete intubation on their first attempt; a significant reduction in the time required to intubate was noted after repeated practice. All levels of naïve EMTs were able to readily visualize the vocal cords through Sunscope and, thereby, reliably insert the endotracheal tube in less than 1 minute, regardless of their skills before testing.