Cormack And Lehane Research Articles

Comparison of face-to-face tracheal intubation and conventional head-end tracheal intubation using Airtraq™ video-laryngoscope in adults - A randomised study.

Tracheal intubation can be difficult in certain scenarios where the head-end of the patient is not accessible as in entrapped casualties. A face-to-face technique using a video-laryngoscope can prove to be useful in such scenarios. However, the two positions of tracheal intubation namely, face-to-face and head-end, using video-laryngoscope have never been compared in patients. Fifty patients of either sex, between 18 and 60 years, ASA class I/II, MPC I/II, scheduled to undergo surgical operations requiring general anesthesia with tracheal intubation were randomly allocated to either Group F (face-to-face intubation) or Group H (head-end intubation). Intubation was performed using Airtraq™ video-laryngoscope in both groups. Time taken for successful intubation, device insertion time, glottic view as per Cormack and Lehane (CL) grade, ease, attempts, the incidence of failed intubation, and hemodynamic parameters were noted. The time taken for successful intubation in Group F was significantly longer than in Group H (38.09 ± 19.45 s vs. 19.32 ± 9.86 s, respectively; P < 0.001). Three cases of failed intubation were noted in Group F compared to none in Group H (P = 0.235). Glottic view, ease, attempts, and hemodynamic parameters were comparable among the groups (P > 0.05). The time taken for successful tracheal intubation was longer in face-to-face technique than in head-end technique in patients with the normal airway. However, both techniques were similar in terms of glottic view, ease of intubation and number of intubation attempts, the incidence of failed intubation, and hemodynamic changes. Therefore, face-to-face tracheal intubation is a good alternative to secure the airway when the head-end is not accessible.

Difficult Intubation Predictor: Comparison Between Ratio Of Height To Thyromental Distance, Mallampati Score And Thyromental Distance

Introduction: The Mallampati score and thyromental distance (TMD) are frequently used to identify challenging laryngoscopies, but their reliability in predicting difficulty is uncertain. This study aims to assess the effectiveness of using the ratio of height to thyromental distance (RHTMD) in predicting difficult visualization of the larynx (DVL) when compared to the Mallampati score and TMD.Method: To achieve this goal, 277 patients who received general anesthesia during elective surgery were evaluated using the Mallampati score, TMD, and RHTMD. The Cormack and Lehane (CL) classification was used to grade the laryngeal view, with CL grade 3 and 4 indicating difficult visualization. The study then determined and compared the area under the curve (AUC), sensitivity, and specificity for each airway predictor.Results: The AUC of RHTMD (85.5%) was better than TMD (82.7%) and significantly better than the Mallampati score (61.4%).Conclusion: RHTMD is more accurate in predicting difficult laryngoscopy than both the Mallampati score and TMD.

Anti-Toothbreaker: A Novel Low-Budget Device Enabling Contactless Dental Protection and a Forbidden Technique during Direct Laryngoscopy for Endotracheal Intubation

Iatrogenic dental injury is the most common complication of conventional laryngoscopy during orotracheal intubation. The main cause is unintended pressure and leverage forces from the hard metal blade of the laryngoscope. The aim of this pilot study was to introduce and test a novel, reusable low-budget device not only providing contactless dental protection during direct laryngoscopy for endotracheal intubation, but also enabling, in contrast to established tooth protectors, active levering with conventional laryngoscopes for easier visualization of the glottis. A constructed prototype for intrahospital usage was evaluated by seven participants on a simulation manikin for airway management. Endotracheal intubation was performed with and without the device using a conventional Macintosh laryngoscope (blade size 4) and a 7.5 mm endotracheal tube (Teleflex Medical GmbH, Fellbach, Germany). Necessary time and success of first pass were determined. Degree of visualization of the glottis with and without the device was stated by the participants according to the Cormack and Lehane (CL) classification system and the Percentage of Glottic Opening (POGO) scoring system. In addition, subjective physical effort, feeling of safety regarding successful intubation, and risk for dental injury were queried on a numeric scale between 1 and 10. All participants except one stated that the intubation procedure was easier with usage of the device than without it. On average, this was subjectively perceived as being approximately 42% (range, 15-65%) easier. In addition, time to first pass success, as well as degree of glottis visualization, subjective physical effort, and feeling of safety regarding risk for dental injury, were clearly better with usage of the device. Concerning feeling of safety regarding successful intubation, there was only a minor advantage. No difference in first pass success rate and number of total attempts could be observed. The Anti-Toothbreaker is a novel, reusable low-budget device which might not only provide contactless dental protection during direct laryngoscopy for endotracheal intubation, but also enables, in contrast to established tooth protectors, active levering with conventional laryngoscopes for easier visualization of the glottis. Future human cadaveric studies are needed to investigate whether these advantages also prove themselves there.

Comparison of Modified Mallampati Classification and Thyromental Height to Predict Difficult Intubation

Introduction: Difficult intubation is an emergency situation that an anaesthetist come across frequently. It is a frequent cause of mortality in practice of anesthesia. Mallampati classification (MPC) of the oropharyngeal structures is a simple test to assess anticipated difficult airway for endotracheal intubation. thyromental height (TMH) test is now also commonly used to predict difficult intubation. Objective: To evaluate diagnostic accuracy of modified mallampati classification and thyromental height using Cormack and Lehane's classification of laryngoscopy as a gold standard. Study Design: Descriptive cross sectional validation study. Setting: Department of Anaesthesia, Benazir Bhutto Hospital, Rawalpindi. Duration: 20-Sep-2021 to 19-Mar-2022. Material and Methods: A total number of 1035 were included in this study. Pre-operatively modified Mallampati test (MMT) and TMH test was performed. Mallampati class III and IV were considered difficult. While TMH height &gt;50 mm was considered as difficult intubation. Difficult intubation equipment’s was ready, i.e. stylet, boogie, LMA, I-gel. General anaesthesia was induced in the operating room after collecting baseline vital signs. After three minutes, a skilled anesthesiologist performed a laryngoscopy while the patient was sniffing. To validate the diagnosis of difficult intubation, the laryngeal view was appraised using a modified Cormack and Lehane (C-L) grading system. Results: Mean age of patients was 40.16±12.19 years. Mean height of patients was 152.94±8.32 cm, mean weight was 65.01±13.59 Kg and Mean body mass index (BMI) was 27.78±5.64 kg/m2. There were 768 (74.20%) males and 267 (25.80%) females. TMH was 77.8% sensitive, 94.6% specific having 70.0% PPV, 96.3% NPV and 92.27% accuracy. On diagnostic accuracy of MMP taking difficult intubation according to standard as gold standard, MMP was 92.4% sensitive, 90.1% specific having 60.2% PPV, 98.6% NPV and 90.3% accuracy. Practical implications: Thyromental Height (TMH) needs more broad usage in multiple settings to be validated as a single most important predictor of difficult laryngoscopy. It will thus be used widely all over the country rendering fewer complications for the patients. Conclusion: TMH was the test that was most sensitive and accurate at foretelling difficult laryngoscopy when compared to the modified Mallampati score. TMH has potential as a single anatomical metric to predict the possibility of a difficult laryngoscopy. Keywords: Mallampati classification, thyromental height, Cormack and Lehane's classification, laryngoscopy.

Comparison of double lumen tube insertion using the McGrath MAC versus direct laryngoscopy in adult patients with a limited glottis view: A prospective interventional study.

Passage of double-lumen tubes (DLT) can be challenging in patients with limited glottis view. This study aims to determine the usefulness of McGrath® MAC videolaryngoscope (VL) in cases with limited glottis view on direct laryngoscopy with Macintosh blade. After study approval and registration of trial, consent was sought from all adult patients planned for elective DLT insertion for lung isolation during the course of general anesthesia. Patients not consenting, less than 18 years, with anticipated difficult mask ventilation or need for rapid sequence induction were excluded. Following routine anesthetic induction, laryngoscopy was attempted by an experienced anesthesiologist using Macintosh scope. If the view obtained was Cormack and Lehane (CL) view IIB and above or the attempt at intubation using DLT failed despite a CL I/IIA view, the patient was included in the trial. The laryngoscope was removed and after ensuring adequate oxygenation and depth of anesthesia, intubation was attempted using McGrath® MAC VL. The percentage of glottis opening (POGO) score was noted for both the scopes. DLT insertion was attempted in 76 patients in the study period. Eight patients were included in the trial on account of limited glottis view/failure with Macintosh scope. Insertion of DLT with McGrath MAC was tried only in six patients, in two patients, the VL was not available for use. The mean (standard deviation) POGO score with Macintosh scope was 9 (±20), which significantly improved with the use of VL to 71 (±24), P = 0.01. McGrath MAC is helpful in inserting DLT in patients with limited glottis view with Macintosh scope.

Evaluation of Glottic View and Intubation Conditions with Sniffing Position Using Three Different Pillow Heights during Direct Laryngoscopy: A Prospective Analytical Study.

Limited studies are available for assessing the optimal pillow height for sniffing position to obtain the best glottic view during laryngoscopy and intubation in the Indian population. This study was designed to evaluate laryngoscopic view and intubation conditions in sniffing position using three different pillow heights (without a pillow, 4 cm, and 7 cm) during direct laryngoscopy. This prospective analytical study was done in a tertiary care teaching institute. In 60 patients, direct laryngoscopy was performed in the sniffing position first without a pillow (0 cm), followed by a 4-cm pillow, and then a 7-cm pillow to assess the glottic view after administration of anesthesia. The laryngoscopic views were graded using the percentage of glottic opening (POGO) score and Cormack and Lehane (CL) grade. The pillow with the best laryngoscopic view was subsequently used to intubate the patient. Intubation difficulty was assessed by the Intubation Difficulty Score (IDS). The patient was followed up for 24 h postoperatively to evaluate postoperative complications due to intubation. The categorical data were expressed in frequency and percentages and analyzed using the Chi-square test. With a 4-cm pillow, there are a lower CL grade and a higher POGO score compared to views without a pillow and a 7-cm pillow which was statistically significant. There is a significantly lesser IDS score with a 4-cm pillow. The sniffing position with a 4-cm pillow provides a better laryngoscopic view and improved intubation condition than without a pillow and a 7-cm pillow in the study population.

Endotracheal intubation in an adult patient of Hallermann-Streiff syndrome-Case report and review of literature.

Dear Editor, Hallermann–Streiff syndrome (HSS), a rare genetic polymalformative dysostic syndrome with only 150 reported cases, was first described in 1893 and is characterized by bird-like facies, hypoplasia of nasal bridge, mandibular hypoplasia, hypertrichosis, ocular abnormalities, severe tracheomalacia, and dwarfism.[1] Because of facial features, airway management is considered difficult in them; however, reports are scarce with only two adult patients previously reported.[1] Paucity of literature on airway management in adult HSS patients prompted us to report the present patient as when syndromes are rare, case reports guide an anesthesiologist for management. A 20-year-old female patient of HSS, American Society of Anesthesiologists grade I, 55 kg, and 154 cm height, was posted for septo-rhinoplasty because of progressive nasal deformity since birth. She had history of snoring not associated with daytime somnolescence or night awakenings. Airway examination revealed microstomia, mouth opening of 2 cm, retrognathia, hyomental distance of 21/2 fingers, large tongue, crowding of teeth, high arched palate, small nares, and modified Mallampati Grade 3 [Figures 1 and 2]. Systemic examination and biochemical profile revealed no abnormality. As patient was anxious regarding awake fiberoptic intubation (FOI), plan was to first assess Cormack and Lehane (CL) grade on laryngoscopy in spontaneously breathing patient without muscle relaxants and in case of failure of endotracheal intubation (ETI) oral FOI under anesthesia was planned (nasal FOI was not possible due to small nares). Informed consent for emergency tracheostomy was taken. In the operation theater, routine monitors were attached. Following preoxygenation with 100% oxygen for 3 min, intravenous ketamine 50 mg with glycopyrrolate 0.2 mg was injected and sevoflurane 2–8% was gradually administered in 4–6 L/min 100% O2 preserving spontaneous respiration. Oropharyngeal airway was required for effective ventilation. Under deep anesthesia, check laryngoscopy with C Mac video laryngoscope size 3 blade revealed CL grade 1. Following this, injection atracurium 0.5 mg/kg was given and a cuffed endotracheal tube 6.5 was inserted successfully at first attempt. Intraoperative analgesia was supplemented with injection fentanyl 2 mcg/kg and paracetamol. Rest of the intraoperative period was uneventful. Surgery lasted for 3 h. At the end of surgery, neuromuscular blockade was reversed with neostigmine and glycopyrrolate and trachea extubated with no adverse sequelae. Patient was observed in recovery room for 2 h and was discharged from ward after 2 days.Figure 1: Frontal view of patient showing small and deformed naresFigure 2: Lateral view of patient showing retrognathia and decreased hyomental distanceThere are only eight reported cases of anesthesia management in HSS patients with two described in adults [Table 1][23456789] of which details of two non-English PubMed reported patients were not found.[46]Table 1: Reported cases of HSS patientsIn the reported adult patients, ETI was anticipated to be difficult; thus, awake ETI was performed in one and lighted stylet via the intubating laryngeal airway was used in the other. However in both patients, ETI was easily performed.[89] In the present patient also, airway management was anticipated to be difficult because of associated facial features like microstomia, <2 cm mouth opening, retrognathia, large tongue, crowding of teeth, and high arched palate. Contrarily ETI was easily established without any manipulations or adjuncts. This could be probably due to presence of small teeth, normal BMI, and adequate mouth opening. Through this case report, we want to highlight that even though adult HSS patients are considered to have difficult ETI, previous two reports including the present one have indicated that in an adult HSS patient, ETI might not be difficult; however, mask ventilation might be challenging. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Prediction of Difficult Tracheal Intubation by Artificial Intelligence: A Prospective Observational Study

Aim: Many predictive clinical tests are used together for preoperative detection of patients with difficult airway risk. In this study, we aimed to predict difficult intubation with different artificial intelligence algorithms using various clinical tests and anthropometric measurements, besides, to evaluate the accuracy performance of Cormack and Lehane (C-L) classification with artificial intelligence. Material and Methods: This study was conducted as a single-blind prospective observational study between 2016 and 2019. A total of 1486 patients with American Society of Anesthesiologists physical status I-III, scheduled to undergo elective surgery and requiring endotracheal intubation, were included. Demographic variables, clinical tests and anthropometric measurements of the patients were recorded. Difficult intubation was evaluated using the 4-grade C-L system according to the easy and difficult intubation criteria. Difficult intubation was tried to predict using 16 different artificial intelligence algorithms. Results: The highest success rate among artificial intelligence algorithms was obtained by the RandomForest method. With this method, difficult intubation was predicted with 92.85% sensitivity, 96.94% specificity, 93.69% positive predictive value and 96.52% negative predictive value. C-L classification accuracy performance also determined as 95.60%. Conclusion: Artificial intelligence has been considerably successful in predicting difficult intubation. Besides, C-L classifications of easy and difficult intubated patients were successfully predicted with artificial intelligence algorithms. Using a 6-grade modified C-L classification for laryngeal view may provide stronger difficult intubation prediction. A safer and more potent prediction in training artificial intelligence can be achieved by adding individual differences and clinical features that support the definition of difficult intubation.

Prediction of Difficult Airway mong Pediatric and Adult Patients Scheduled for Ophthalmological Surgeries under General Anesthesia

Objective: To evaluate the sensitivity and specificity of bedside tests for prediction of difficult airway scheduled for ophthalmological surgeries under general anesthesia.Methods: This prospective study was carried out at Armed Forces Institute of Ophthalmology, Rawalpindi, Pakistan from March 2020 to October 2020. All pediatric and adult patients with American society of anesthesiologist grade I to IV undergoing elective ophthalmological surgeries under general anesthesia were consecutively enrolled. Mallampati grading, sternomental, thyromental distance, and mouth opening used as the predictors tools whereas Cormack and Lehane (CL) classification validated with on table laryngoscopy. Grade I and II were assigned as easy laryngoscopy whereas grade III and IV were declared as difficult intubation.Results: Of 232 patients, difficult intubation was observed in 36 (15.5%). Sensitivity and specificity of thyromental distance was 80.5% and 99.4% respectively. Whereas sensitivity of mouth opening was 66.6% and specificity was 99.4%. In case of sternomental distance, sensitivity and specificity corresponded to 61.6% and 100% respectively. The sensitivity and specificity of Modified Mallampati Grading was 97.2% and 96.4% respectively. The relationship between CL grading and MMC showed that all the patients with CL grade I had Malampati grade I, i.e., 28 (100%), while all patients with CL grade IV had Malampati grade IV, i.e., 7 (100%).Conclusion: Bedside tests prove to be useful parameters for prediction of difficult airway at pre-anesthesia assessment among which Mallampati test is most sensitive and specific, subsequently ensuring availability of difficult intubation equipment, which is a focus of concern in third world countries.

Evaluation of Intubating Conditions during Direct Laryngoscopy using Sniffing Position and Simple Head Extension- A Randomised Clinical Trial

Introduction: Optimal laryngeal visualisation during direct laryngoscopy requires adequate positioning of the head and neck. Traditionally, Sniffing Position (SP) is the recommended position to provide superior glottic visualisation. However various studies in recent past have challenged the superiority of SP. Aim: To evaluate whether SP provides better glottic visualisation and ease of intubation {as assessed by total Intubation Difficulty Score (IDS) score as well as its individual components} compared to Simple Head Extension (SHE) during direct laryngoscopy and endotracheal intubation. Materials and Methods: The randomised clinical trial was conducted at GGS Medical College and Hospital, Faridkot, Punjab, India, from May 2019 to October 2020, on 220 patients. Patients undergoing elective surgeries under general anaesthesia were randomly divided into two groups. Laryngoscopy and tracheal intubation in Group I was done in SP, which was obtained by placing a non compressible pillow of height 8 cm under the patient’s head. Patients in Group II underwent laryngoscopy and tracheal intubation in SHE position. Glottic visualisation using modified Cormack and Lehane (CL) grades, IDS and sympathetic responses between the two groups were studied. The data was compared using student’s t-test and Chi-square test. Results: Cormack and Lehane Grade I was seen in 69 (62.7%) of patients in Group I as against 51(46.4%) of patients in Group II (p-value=0.015). Easy intubation (total IDS score=0) was seen in a greater number of patients in Group I (60.9%) as compared to Group II (40.95%) (p-value=0.003). Slight difficulty in intubation (total IDS score=1-5) was encountered in 50.0% of patients in group II (n=55) and 35.5% of patients in group I (n=39) (p-value=0.029). Conclusion: The present study concluded that use of SP resulted in better glottic visualisation and was associated with favourable intubation conditions as compared to SHE position.

A Comparative Study between Truview PCD Video Laryngoscope and Macintosh Laryngoscope with Respect to Intubation Quality and Hemodynamic Changes.

Background and Aims:Video laryngoscopes resemble traditional laryngoscopes, but they have a video chip embedded in the tip of laryngoscope blade. This enables the operator to “look around the corners” which is not possible with conventional direct laryngoscopes. The present study was undertaken to compare Truview video laryngoscope and Macintosh laryngoscope for glottis visualization, ease of tracheal intubation, and associated hemodynamic response.Setting:The study was conducted in operation theater in a medical college.Study Design:It was a randomized prospective observational study.Materials and Methods:Sixty patients of American Society of Anesthesiologists Grade 1 and 2 of either sex aged 18–60 years who were scheduled to undergo elective surgery requiring general anesthesia with orotracheal intubation were selected. In patients of Group T (n = 30), intubation was done using Truview video laryngoscope, while in Group M (n = 30), intubation was done using Macintosh laryngoscope. Various airway and hemodynamic parameters were assessed and compared.Statistical Analysis:Statistical analysis was done using Chi-square test, paired and unpaired Student's t-test, and ANOVA test. P < 0.05 is considered statistically significant.Results:Distribution of modified Mallampati Class (MMPC), ease of laryngoscopic blade insertion, and size of cuffed endotracheal tube used were statistically comparable in both the groups. The time to intubation was more in Group T (37.16 ± 8.23 s) as compared to Group M (29.80 ± 6.75 s). There was a statistically significant better modified Cormack and Lehane (CL) grading view obtained in Group T as compared to Group M (P = 0.025). CL Grades 2 and 3 were not seen in any of either of the group. The mean intubation difficulty score (IDS) was significantly lower in Group T (0.3 ± 0.60) as compared to Group M (0.73 ± 0.86). In both the Groups T and M, the mean heart rate, systolic blood pressure (BP), and diastolic BP were significantly increased from baseline for up to 3 min after laryngoscopy, but they were comparable between the two groups all the time.Conclusion:Truview propaganda cum distribution laryngoscope provides a better glottis view than the Macintosh laryngoscope. Although it requires a longer time to intubate using Truview, the overall IDS score was lower as compared to Macintosh laryngoscope. Hemodynamic changes remained similar in both the groups.

Validation of clinical versus ultrasound parameters in assessment of airway

Background & AimsEnsuring adequate ventilation and oxygenation requires comprehensive knowledge and specific skills to secure the airway. We hypothesized that airway assessment using ultrasound is superior in predicting difficult laryngoscopy and aimed to compare airway ultrasound with clinical assessment to predict it. MethodologyCross sectional study on 100 adults (65 females) undergoing elective surgeries with tracheal intubation in a tertiary centre were subjected to 2 staged airway assessment, both clinical and ultrasound. Airway ultrasound parameters recorded were anteroposterior thickness of geniohyoid muscle, distance from skin to hyoid bone, thyrohyoid membrane and true vocal cords. The Cormack and Lehane (CL) grade at laryngoscopy and Intubation Difficulty Scale (IDS) scores were noted. Results were analysed using Kappa statistics. ResultsNeck circumference and distance from skin to epiglottis at the level of thyrohyoid membrane (DSETM) were significant predictors of difficult laryngoscopy with a cut-off value of ≥35.8 cm (33% were predicted to be difficult however only 4% cases posed difficulty in laryngoscopy) and 1.9 ± 0.3 cm respectively. ConclusionAirway ultrasound is an objective and cost-effective modality in the anaesthesiologists’ armamentarium. DSETM ≥1.90 cm differentiated between easy and difficult laryngoscopy. Ultrasonography assessment adds an incremental diagnostic value to clinical screening tests.

A randomized controlled trial comparing McGRATH series 5 videolaryngoscope with the Macintosh laryngoscope for nasotracheal intubation.

Background and Aims:The aim of this study was to compare the efficacy of McGRATH series 5 videolaryngoscope (VL) with Macintosh laryngoscope for nasotracheal intubation (NTI) in patients without anticipated difficult airways undergoing head and neck cancer surgeries.Material and Methods:We randomized 60 adult patients for NTI by experienced anesthetists with either Macintosh laryngoscope or McGRATH series 5 VL (VL group). The primary objective was to compare time taken for intubation (TTI). The secondary objectives included success rates, number of attempts, need for optimization maneuvers, Cormack and Lehane (CL) grade, and percentage of difficult intubations.Results:The mean TTI in the VL group was 43 (±10.6) versus 75 (±38.0) s in the Macintosh group (99% CI: 12.5; –51.6 s; P < 0.001). The overall intubation success rate was 100% in both groups. All 29 (100%) patients in the VL group were intubated in the first attempt versus 26 (86%) patients in the Macintosh group (99% CI –5; 33%; P = 0.11). In the Macintosh group, 20 (66%) patients needed optimization maneuver versus none in the VL group (99% CI 40; 91%; P < 0.001). In the VL group, 28 (96%) patients had a CL grade 1 view versus 9 (31%) in Macintosh group (99% CI 38; 92%; P < 0.001). There were no difficult intubations in the VL group versus 3 (10%) in the Macintosh group (99% CI: 7; 28%; P = 0.237). There was no trauma to oropharyngeal structures in either group.Conclusion:The McGRATH series 5 VL has faster TTI, better glottic visualization, and less need for optimization maneuvers than the Macintosh laryngoscope for NTI in patients with unanticipated difficult airways, when performed by experienced anesthetists.

McGrath MAC video laryngoscope versus direct laryngoscopy for the placement of double-lumen tubes: A randomised control trial

Background and Aims:Role of video laryngoscopes (VLs) in the management of difficult airway with single-lumen tubes (SLTs) is established. VLs provide improved glottis view but are associated with longer time to intubate (TTI). We aimed to compare the TTI for double-lumen tube (DLT) insertion using the McGrath® MAC VL versus direct Macintosh laryngoscope (DL).Methods:Eleven senior anaesthesiologists experienced in SLT insertion, but not DLT insertion with VL participated. Seventy-four adults belonging to American Society of Anesthesiologists physical status I–II posted for elective surgery needing lung isolation were randomised to both intubator and laryngoscope (VL/DL). Primary endpoint was TTI; secondary endpoints included glottic view assessed by the Cormack and Lehane (CL) grade, need for external laryngeal manipulation, ease of intubation [scored using Numeric Rating Scale (1 – easiest, 10 – most difficult)] and associated complications. TTI was compared using Student's t-test.Results:No difference was found in TTI with DL and VL [(56.6 ± 14) s vs (64.4 ± 24) s, P = 0.104] as well as ease of use of laryngoscope [median score of 2 (1–3) in both]. Use of VL resulted in more patients with CL I glottic view – 86.0% versus 58.0% (P = 0.007). Fewer patients required external laryngeal manipulations (19% vs 47%, P = 0.013), and complications were fewer in the VL group (5% vs 24%, P = 0.023).Conclusion:TTI for DLT insertion was similar with VL and DL. However, VL was associated with better glottis visualisation, reduced need of external laryngeal manipulation and fewer complications.

Comparing the intubation effectiveness of two different laryngoscopes in patients with cerebral palsy

Objective: In patients with expected airway difficulties, specific preparatory and auxiliary equipment is required before general anesthesia. The aim of this study was to compare the intubation efficacy of Macintosh laryngoscope with that of the McGrath MAC video laryngoscope in patients with cerebral palsy. Materials and Methods: The study was conducted in forty patients (aged 4-15) with cerebral palsy who were scheduled to undergo dental treatment. Intubations were performed in patients randomly assigned to the McGrath MAC video laryngoscope or the Macintosh laryngoscope. The characteristics of the patients, mean arterial blood pressure, heart rate, end-tidal carbon dioxide, and peripheral oxygen saturation were measured. The intubation success, intubation time, Cormack and Lehane grades, number of trials, need for neck extension, and complications were recorded. Results: When both groups were compared in terms of the glottic view, intubation time, and need for neck extension, there was no significant difference (p = 0.542, p = 0.779, and p = 1.000, respectively). All the intubations were performed successfully at the first attempt in both groups, and no complications were recorded. Conclusion: Although our study included patients with cerebral palsy, in which musculoskeletal anomalies are common, sufficient muscle relaxation for intubation after general anesthesia was achieved in all the patients. There was no evidence of intubation difficulty in either group of patients, and cerebral palsy, with its existing deformities, did not affect the intubation success or complication rate. No additional advantages of using video laryngoscopy in patients with cerebral palsy were found.

The Assessment of Risk Factors for Difficult Intubation in Thyroid Patients.

We aimed to assess possible risk factors related to difficult intubation in patients undergoing thyroid surgery. We prospectively collected data of 200 patients scheduled for thyroid surgery. Clinical risk factors were defined as: Mallampati score, interincisor gap, thyromental distance, sternomental distance, range of neck motion, body mass index, neck circumference, goiter, the presence of radiological findings suggesting compression and thyroid weight. All evaluations were performed with Macintosh assessed for Cormack and Lehane (CL) classification and modified intubation difficulty scale (MIDS). It was observed that the proportion of patients with a thyroid weight ≥40g, goiter, a Macintosh CL score=3-4 and the mean neck circumference were significantly higher in the group with a MIDS score >5 (p=0.018, p=0.011, p<0.001, respectively). The presence of a palpable goiter, thyroid weight ≥40g and thyromental distance <6.5cm were risk factors associated with difficult intubation in the multivariate regression model.

Ease in Bag and Mask Ventilation: Is Ankyloglossia in a Child with Micrognathia a Blessing in Disguise?

Sir, A review of the pediatric closed claim cases reveals inadequate ventilation or failed intubation among common causes of anesthesia-related deaths. Unlike adults, no validated classification exists for difficult airway assessment in pediatric population.[1] Anticipated difficult airway includes congenital syndromes or anatomy such as temporomandibular joint dysfunction or neck contracture. A common feature of many of these syndromes is micrognathia, ankyloglossia, or both leading to difficult glottic visualization.[2] Mallampati classification does not accurately predict a poor glottis visualization in the pediatric population.[1] We discuss difficult airway management of a 3-year-old male child with micrognathia and ankyloglossia, diagnosed with Grade V left vesicoureteric reflux and listed for laparoscopic transperitoneal left ureteric reimplantation [Figure 1].Figure 1: Child with micrognathiaAfter adequate nil per oral status, the child was brought to operating room without any premedication. Routine anaesthesia monitors was placed and age appropriate difficult airway trolley was kept on standby. Anesthesia was induced with inhaled sevoflurane 6–8%, intravenous access secured; midazolam 0.3 mg, fentanyl 30 μg, and propofol 10 mg were administered. Under spontaneous ventilation, conventional direct laryngoscopy (DL) with straight blade was attempted. A Cormack and Lehane (CL) Grade IV laryngoscopic view was encountered owing to the tongue falling on either side of the blade. A repeat attempt was done with curved blade, but the tongue could not be deviated to the left side because of ankyloglossia. Two failed attempts at DL prompted us to use GlideScope® video laryngoscope (GVL) which enabled a CL Grade III glottic visualization, and we were able to intubate the trachea with 4.5 sized uncuffed endotracheal tube. Subsequently, the child was paralyzed with 2 mg of vecuronium and maintained with oxygen, air, and sevoflurane mixture. During the entire episode till successful intubation, we were able to maintain oxygenation. After completion of surgery and return of spontaneous ventilation, muscle relaxation was reversed and child extubated. Keeping in mind the nature, duration, and positioning during surgery, we ruled out the use of laryngeal mask airway (LMA) as our first tool to secure the airway. Kuzma et al. used LMA assisted fiberoptic-guided intubation for a child with Escobar syndrome.[3] Airtraq optical laryngoscope and GVL have been used successfully in pediatric patients with the craniofacial anomalies.[4] We are of the opinion that ankyloglossia, by preventing tongue fall, allowed us to ventilate the patient and gave us precious time to exercise other options of securing the airway. While ankyloglossia made bag-mask ventilation easy, it along with micrognathia resulted in limited space for blade maneuverability during DL and GVL, thereby hampering glottic visualization. Although we used GVL to secure the airway, we wish to suggest that rather than taking multiple attempts at DL or GVL, fiberoptic-guided intubation should be the first choice for endotracheal intubation. Further, a child with micrognathia should always be evaluated for ankyloglossia during preanesthetic evaluation. However, a larger study in children with ankyloglossia and micrognathia is required to further cement our suggestion. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

The Fast and Easy Way for Double-Lumen Tube Intubation: Individual Angle-Modification.

To find the faster and easier way than the existing intubating technique for double-lumen tube, we modified the angle of double-lumen tube according to an individual’s upper airway anatomy and compared the time needed and the number of attempts for successful intubation between individually angle-modified and non-modified double-lumen tubes. Adult patients undergoing elective thoracic surgery were randomly allocated in either non-angle-modified (Group N, n = 54) or angle-modified (Group M, n = 54) groups. During mask ventilation in the sniffing position, angle-modification was performed in Group M as follows: the distal tip of the tube was placed at the level of the cricoid cartilage and the shaft was bent at the intersection of the oral and pharyngeal axes estimated from the patient’s surface anatomy. The time needed and the number of attempts for successful intubation and Cormack and Lehane (C-L) grade were recorded. Overall median intubation time (sec) was significantly shorter in Group M than in Group N [10.2 vs. 15.1, P<0.001]. In addition, Group M showed the shorter median intubation time (sec) in C-L grades I-III [8.2 vs. 11.1 in C-L grade I, (P = 0.003), 10.3 vs. 15.3 in II, (P = 0.001), and 11.8 vs. 27.9 in III, (P<0.001), respectively]. Moreover, all intubation was successfully performed at the first attempt in patients with C-L grades I-III in Group M (P = 0.027). Our study showed an individual angle-modification would be useful for the fast and easy intubation of double-lumen tube in patients with C-L grades I-III.Trial Registration: ClinicalTrials.gov NCT02190032

Comparison of factors associated with desaturation in prehospital emergency anaesthesia in primary and secondary retrievals

ObjectiveTo investigate the incidence and factors associated with desaturation related to emergency intubations within an aeromedical retrieval service pertaining to both primary prehospital and secondary interhospital missions.MethodsA retrospective analysis of...

A Comparison of Two Video laryngoscopes: Truview and Kingvision in Routine Airway Management

Background: With advances in technology, intubation using video laryngoscopy has been gaining popularity, particularly in patients with difficult airways or as rescue devices in failed intubation attempts. Their routine use is, however, an uncommon occurrence. This clinical trial was carried out to support their use in elective airway management. Objective: To evaluate the effectiveness of kingvision video laryngoscope (KVL) in comparison with the Truview video laryngoscope (TVL) in routine airway management. Methods: We studied 60 subjects requiring orotracheal intubation during general anaesthesia for elective surgeries. They were randomly assigned into two groups to undergo tracheal intubation using either a TVL (n=30) or KVL (n=30) .Characteristics and consequences of airway management were evaluated. The primary outcomes were the percentage of glottic opening (POGO) and ease of intubation and secondary outcomes were Cormack and Lehane (CL) grading, TTI (time taken for intubation) and successful placement of endotracheal tube (ETT). Results: Both the VLs were comparable with respect to primary and secondary outcomes except TTI which was more with KVL. Conclusion: We opine that both TVL and KVL provide a better laryngoscopic view in routine airway management, but KVL does not have an extra benefit over TVL otherwise, further indicating the need for more experience with the use of a KVL.