Simulated Difficult Airway Research Articles

Comparison of different types of stylets with no-stylet technique for intubation with C-MAC D-Blade® videolaryngoscope in simulated difficult airway: A prospective randomized study.

Objective: The angulated C-MAC D-Blade videolaryngoscope (VL) is designed for difficult intubation and may not be compatible with standard PVC endotracheal tubes (ETTs). This study was planned to compare efficacy of C-MAC, D-Blade VL using ETT with three different stylets versus no-stylet in patients undergoing tracheal intubation with simulated difficult airway. Methods: After obtaining written informed consent and IEC approval, a total of 144 adult patients were allocated to four groups of 36 each using no-stylet or different types of stylets. The four groups were as follows: Group NS: no-stylet; Group CS: C-MAC stylet; Group DS: D-Blade-type stylet; Group HS: hockey-stick shaped stylet. A rigid appropriate-sized Philadelphia cervical collar was placed around the neck to simulate difficult airway, and C-MAC D-Blade VL was used for intubation. The duration of each intubation stage and attempts were evaluated. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 22.0 (IBM SPSS Corp.; Armonk, NY, USA), and appropriate tests for different variables were applied. Appropriately, Student’s t test, Chi-square test, Mann–Whitney U test, and one-way ANOVA test were applied. Results: Similar Cormack Lehane grade glottic view was observed in all groups. The number of attempts and duration of intubation were significantly greater using NS group than for other groups. Additional laryngeal manipulation was required in all cases in Group NS, compared to one, zero, and two cases in Groups CS, DS, and HS, respectively (P < .001). Conclusion: Use of Hockey stick shaped stylet, D-Blade-shaped stylet, and C-MAC stylet decreased the total intubation duration in patients with simulated difficult airway.

Comparison of the novel VieScope with conventional and video laryngoscope in a difficult airway scenario \u2013 a randomized, controlled simulation trial

BackgroundEndotracheal intubation continues to be the gold standard for securing the airway in emergency situations. Difficult intubation is still a dreadful situation when securing the airway.ObjectiveTo compare VieScope with Glidescope and conventional Macintosh laryngoscopy (MAC) in a simulated difficult airway situation.MethodsIn this randomized controlled simulation trial, 35 anesthesiologists performed endotracheal intubation using VieScope, GlideScope and MAC in a randomized order on a certified airway manikin with difficult airway.ResultsFor the primary endpoint of correct tube position, no statistical difference was found (p = 0.137). Time until intubation for GlideScope (27.5 ± 20.3 s) and MAC (20.8 ± 8.1 s) were shorter compared to the VieScope (36.3 ± 10.1 s). Time to first ventilation, GlideScope (39.3 ± 21.6 s) and MAC (31.9 ± 9.5 s) were also shorter compared to the VieScope (46.5 ± 12.4 s). There was no difference shown between handling time for VieScope (20.7 ± 7.0 s) and time until intubation with GlideScope or MAC. Participants stated a better Cormack & Lehane Score with VieScope, compared to direct laryngoscopy.ConclusionRate of correct tracheal tube position was comparable between the three devices. Time to intubation and ventilation were shorter with MAC and Glidescope compared to VieScope. It did however show a comparable handling time to video laryngoscopy and MAC. It also did show a better visualization of the airway in the Cormack & Lehane Score compared to MAC.Trial registrationThe study was registered at the German Clinical Trials Register www.drks.de (Identifier: DRKS00024968) on March 31st 2021.

Innovation in low-cost video-laryngoscopy: Intubator V1-Indirect compared with Storz C-MAC in a simulated difficult airway

BackgroundVideo laryngoscopy has directly impacted airway management, with numerous studies demonstrating its utility in clinical management of anatomically difficult airways. However, availability of video laryngoscopes in all clinical areas has been limited by the relatively high cost. We used smartphone technology, miniature cameras and three-dimensional printing to design and create an innovative low-cost hyperangulated video laryngoscope. This has the potential to make the technique more widely available. The aim of this study was to determine if time to intubation with the novel device was clinically equivalent to an existing gold-standard video laryngoscope (Storz CMAC with Dörges blade). MethodsWe conducted a randomised, controlled, cross-over equivalence study with 100 skilled practitioners who had previous video laryngoscopy experience. Participants received instruction on the new device, and adequate opportunity to practice. Intubations were then performed in a randomised order on a mannikin simulating a difficult airway. Video recordings of each intubation were analysed by two independent investigators to determine time to intubation. A mean difference in intubation time of less than 10 s was determined a priori to denote clinical equivalence. ResultsMean difference in intubation time between the devices was 4.9 s, (two one-sided test 95%CI: 2.3–7.5 s). The innovative low-cost VL was thus clinically equivalent to the industry standard in a simulated difficult airway. Further testing in vivo in a clinical environment is needed. ConclusionThe results of this study show that a low-cost disposable hyperangulated video laryngoscope is clinically equivalent to the industry standard in a simulated difficult airway. In the context of the current global pandemic, video laryngoscopy has been advised in nearly all airway guidelines. Access to a low-cost VL which does not require reprocessing may be of great value.

The Performance of Flexible Tip Bougie™ in Intubating Simulated Difficult Airway Model.

This prospective, randomized, cross-over study compared the performance of the novel Flexible Tip Bougie™ (FTB) with a conventional bougie as an intubation aid in a simulated difficult airway manikin model among anaesthesiology trainees with regards of first pass success rate, time to intubation, number of attempts and ease of use. Sixty-two anesthesiology trainees, novice to the usage of FTB, participated in this study. Following a video demonstration, each participant performed endotracheal intubation on a manikin standardized to a difficult airway view. Each participant performed direct laryngoscopy and intubated the manikin using a conventional bougie and FTB, at least 1 day in between devices, in a randomized order. The first pass success rate was significantly higher with FTB (98.4%) compared to conventional bougie (85.5%), p = 0.008. The median time to intubation was significantly faster when using FTB, median = 32.0 s [Interquartile range (IQR): 23.8–41.3 s] compared to when using conventional bougie, median = 41.5 s (IQR: 31.8–69.5 s), p < 0.001. The FTB required significantly less intubation attempts compared to conventional bougie, p = 0.024. The overall ease of use, scored on a Likert scale from 1 to 5, was significantly higher in the FTB (4.26 ± 0.53) compared to the conventional bougie (3.19 ± 0.83), p < 0.001. This simulated difficult airway manikin study finding suggested that FTB is a useful adjunct for difficult airway intubation. The FTB offered a higher first pass success rate with a faster time to intubation and less required attempts.

Simulated Difficult Airway: CMAC D Blade or Glidescope?

Background Manual in line axial stabilization (MIAS) technique is recommended for stabilizing the cervical spine in suspected cervical spine injuries, but creates special challenges in airway management. The present study compares two different video laryngoscope (VL) namely CMAC D blade (CMAC) and glidescope blade 4 (GL) for intubation in patients with a simulated difficult airway by applying MIAS. Methodology This was a hospital based prospective, single blind, randomized comparative pilot study. A total of 60 patients, having no predictors of difficult airway and scheduled for elective surgery were recruited and randomized into 2 equal sized groups based on a software generated random sequence. The Primary outcome was Intubation Difficulty Score (IDS), whereas the time taken to secure the airway and obtain a capnographic wave, Cormack Lehane Grade (CL) and hemodynamic parameter comprised the secondary outcomes. The following tests- Fischer’s exact test, Chi-square test and Student ‘t’ test used for analysis. Results GL group had an IDS score of zero in 46.7% patients compared to 26.7% in CMAC group, IDS score of 0-5 was found to be 50 % in GL group while CMAC group scored 66.6%. This was found to be statistically insignificant (p=0.18). Time taken for successful intubation was 43.70±9.91 and 54.60±20.47 seconds (p=0.011) in GL and CMAC group respectively. Conclusions VL is a vital tool in the management of difficult airway. The superiority of one over the other device tested here could not be established, although GL showed slightly better scores but were statistically insignificant.

A Randomised Control Trial Comparing the Efficacy of LMA-Supreme and I-Gel as Rescue Ventilatory Device in Patients with Simulated Difficult Airway Undergoing Anaesthesia with Controlled Ventilation

Introduction: In an unanticipated difficult airway or in an emergency situation of cannot-intubate-cannot-ventilate scenario, Supraglottic Airway Devices (SGD) are recommended as rescue devices for establishing airway quickly to prevent hypoxia. Aim: To compare efficacy of i-gel airway and Laryngeal Mask Airway supreme (LMA supreme) as ventilatory devices and the time taken for their insertion in anaesthetised and paralysed patients with simulated difficult airway. Materials and Methods: One hundred and eighty adult patients with simulated difficult airway were randomly allocated to two groups of 90 patients each. In group I: i-gel and in group S: LMA supreme was inserted. Primary outcome studied was time taken for insertion of SGD. Secondary outcomes were the number of attempts taken for insertion of device, oropharyngeal leak pressure, ease of gastric catheter insertion, fibreoptic bronchoscopic view of anatomical alignment of device with glottic opening. Quantitative variables were compared using unpaired t-test/Mann-Whitney Test, between the two groups. Qualitative variable were compared using Chi-Square test/Fisher’s-exact test. Results: Total time taken for successful insertion was significantly shorter with group i-gel as compared to group LMA supreme {median (IQR) {19 (18.25-21)} versus {24 (23-24)} with p-value ≤0.0001. Overall success rate of insertion (96.67% vs 97.78%, p=1.000) and oropharyngeal leak pressure (p-value=0.555) of i-gel and LMA-S were comparable. i-gel has better anatomic alignment with glottic opening as compared to LMA-S (p-value ≤0.0001). Gastric tube insertion was easy in all patients in both the groups. Conclusion: Shorter time for the insertion of i-gel was observed due to absence of inflatable cuff, although both LMA-S and i-gel are equally efficacious as ventilatory devices in patients with simulated difficult airway under general anaesthesia with controlled ventilation.

A Prospective, Longitudinal Study on Effectiveness of King Vision® Video Assisted Laryngoscope and McCoy Laryngoscope in Patients with Simulated Restricted Neck Mobility

Introduction: Successful airway management in patients with restricted cervical spine movement is always very challenging as there is no consensus regarding management of difficult airway in such patients with limited or no cervical spine mobility. Aim: To assess whether the King Vision® Video Laryngoscope (KVVL) provides a better view of the glottis and has higher success rate of tracheal intubation than McCoy laryngoscope in patients with simulated difficult airway. Materials and Methods: A prospective, longitudinal, comparative study was conducted with prior approval from Institutional Ethics Committee, 100 patients were divided equally (n=50) into group V {Video Laryngoscope (VL)} and group M (McCoy laryngoscope). Time required for laryngoscopy and intubation, any damage to teeth or soft tissue injury was noted and view of the glottis was graded using a modified classification reported by Cormack and Lehane. Qualitative data (sex, American Society of Anesthesiologists (ASA) physical status, Mallampati classification, Cormack and Lehane glottis view grade, number of laryngoscopic attempts, number of optimisation maneuver required etc.,) were compared between the groups. Chi-square test (χ2) and Fisher-exact test were used. Results: The success on first attempt of laryngoscopy was significantly greater (p=0.014), time taken to do the procedure of laryngoscopy (p&lt;0.001) and duration of intubation (p&lt;0.001) was significantly lesser in the group V patients as compared to group M. Incidence of procedural dental injury was totally absent in group V, whereas four cases were recorded in group M. Optimisation maneuver was required in 50% of the group M patients as compared to 10% of group V (p&lt;0.001). Changes in baseline parameters like pulse, Blood Pressure (BP) was noted more in group M (p&lt;0.01) probably owing to the greater mean duration of intubation. Conclusion: KVVL appears to possess more advantages over the McCoy laryngoscope in respect to ease of viewing glottis, reduced duration of laryngoscopy and intubation, lesser complications and haemodynamic instability.

Learning curve and performance in simulated difficult airway for the novel C-MAC® video-stylet and C-MAC® Macintosh video laryngoscope: A prospective randomized manikin trial.

Difficult airways can be managed with a range of devices, with video laryngoscopes (VLs) being the most common. The C-MAC® Video-Stylet (VS; Karl-Storz Germany), a hybrid between a flexible and a rigid intubation endoscope, has been recently introduced. The aim of this study is to investigate the performance of the VS compared to a VL (C-MAC Macintosh blade, Karl-Storz Germany) with regards to the learning curve for each device and its ability to manage a simulated difficult airway manikin. This is a single-center, prospective, randomized, crossover study involving twenty-one anesthesia residents performing intubations on a Bill 1™ (VBM, Germany) airway manikin model. After a standardized introduction, six randomized attempts with VL and VS were performed on the manikin. This was followed by intubation in a simulated difficult airway (cervical collar and inflated tongue) with both devices in a randomized fashion. The primary end-point of this study was the total time to intubation. All continuous variables were expressed as the median [interquartile range] and analyzed using the Mann-Whitney U test. A 2-way ANOVA with Bonferroni’s post hoc test was used to compare both devices at each trial. All reported p values are two sided. The median total time to intubation on a simulated difficult airway was faster with the VS compared to VL (17 [13.5–25] sec vs 23 [18.5–26.5] sec, respectively; 95% CI; P = 0.031). Additionally, on a normal airway manikin, the VS has a comparable learning curve to the VL. In this manikin-based study, the novel VS was comparable to the VL in terms of learning curve in a normal airway. In a simulated difficult airway, the total time to intubation, though likely not clinically relevant, was faster with the VS to the VL. However, given the above findings, this study justifies further human clinical trials with the VS to see if similar benefits–faster time to intubation and similar learning curve to VL–are replicated clinically.

Proficiencies of military medical officers in intubating difficult airways

BackgroundThis study sheds light on the proficiency of military medical officers who had received between 2 and 3 years of post-graduate training, in the handling of the difficult airway in a trauma manikin simulator using direct and video laryngoscopes.MethodOne hundred thirty-three doctors from the Singapore Armed Forces Medical Officer Cadet Course were assessed using high-fidelity simulator models with standardised difficult airways (simulator with tongue-swelling and cervical collar). They used the Macintosh direct laryngoscope (DL), King Vision channelled-blade laryngoscope (KVC), King Vision non-channelled blade laryngoscope (KVNC), and the McGrath (MG) laryngoscope on the same model in a randomised sequence. The intubation success rates and time to intubation were recorded and analysed for the study.ResultsThe medical officers had a 71.4% intubation success rate with the DL on the difficult airway trauma simulator model and the mean time to intubation of 40.1 s. With the KVC, the success rate is 86.5% with mean intubation time of 40.4 s. The KVNC produced 24.8% success rate, with mean time to intubation of 53.2 s. The MG laryngoscope produced 85.0% success rate, with a mean time of intubation of 37.4 s.ConclusionMilitary medical officers with 2–3 years of post-graduate training had a success rate of 71.4% success rate intubating a simulated difficult airway in a trauma setting using a DL. Success rates were improved with the use of KVC and the MG laryngoscope, but was worse with the KVNC.

Effect of an Aerosol Box on Intubation in Simulated Emergency Department Airways: A Randomized Crossover Study.

IntroductionThe use of transparent plastic aerosol boxes as protective barriers during endotracheal intubation has been advocated during the severe acute respiratory syndrome coronavirus 2 pandemic. There is evidence of worldwide distribution of such devices, but some experts have warned of possible negative impacts of their use. The objective of this study was to measure the effect of an aerosol box on intubation performance across a variety of simulated difficult airway scenarios in the emergency department.MethodsThis was a randomized, crossover design study. Participants were randomized to intubate one of five airway scenarios with and without an aerosol box in place, with randomization of intubation sequence. The primary outcome was time to intubation. Secondary outcomes included number of intubation attempts, Cormack-Lehane view, percent of glottic opening, and resident physician perception of intubation difficulty.ResultsForty-eight residents performed 96 intubations. Time to intubation was significantly longer with box use than without (mean 17 seconds [range 6–68 seconds] vs mean 10 seconds [range 5–40 seconds], p <0.001). Participants perceived intubation as being significantly more difficult with the aerosol box. There were no significant differences in the number of attempts or quality of view obtained.ConclusionUse of an aerosol box during difficult endotracheal intubation increases the time to intubation and perceived difficulty across a range of simulated ED patients.

VieScope® laryngoscope versus Macintosh laryngoscope during difficult intubation performed by paramedics: a randomized cross-over manikin trial

INTRODUCTION: The aim of this study was to evaluate intubation performance by paramedics using Macintosh laryngoscope and VieScope® laryngoscope under simulated difficult airway conditions. METHODS: In a randomized, single-blinded, cross-over simulation trial, 42 paramedics performed endotracheal intubation using VieScope® and Macintosh (MAC) laryngoscopes in two difficult airway scenarios: (A) tongue edema, (B) manual cervical inline stabilization. The order of participants and intubation methods was random. Time to ventilation constituted the primary outcome, and the secondary outcomes were the success rate of first intubation attempt, overall intubation success rate, Cormack and Lehane grade, and ease of use. RESULTS: In scenario A, the median overall intubation time was 55s (46–109) in the MAC group and 30.5s (26–35) in the VieScope® group (p < 0.001). The efficacy of the first intubation attempt with MAC and Vie- Scope® varied and amounted to 64.3% vs. 95.2% (p < 0.001). During scenario B, VieScope® offered better intubation conditions than MAC (p < 0.001), including shorter intubation time, higher first attempt and overall intubation success rates, as well as better glottic view. CONCLUSIONS: In this simulation trial, we found that VieScope® could be successfully used for intubation in difficult airways by paramedics with little simulation experience with this device. VieScope® was associated with shorter time and higher success rates of intubation attempt compared with MAC. Nevertheless, we recommend that the performance of VieScope® and MAC should be further evaluated in the clinical setting to confirm our results.

Endotracheal intubation in a ramped versus supine position in the emergency department: A randomised crossover manikin study

Background: Performing endotracheal intubation by placing patients in a ramped position has been shown to improve the ease of intubation and to reduce complications. The above findings, however, were only established in the operation theatre and intensive care settings. Objective: In order to establish the findings in the setting of the emergency department, we attempt to compare the ramped versus supine positions in normal and difficult airway scenarios. Methods: Medical doctors practicing at a local Accident and Emergency Department were recruited into a crossover randomised study. They were asked to perform intubations on a manikin in four scenarios. The manikin was put in a ramp or supine position. In addition, the manikin settings were adjusted to normal and difficult airways. Results: A total of 39 Accident and Emergency Department doctors were recruited. There was no statistically significant difference in the first-attempt success rates using the ramped position compared to supine position in either airway scenario (100% vs. 97.4%, P = 1 in normal airway, 79.5% vs. 74.4%, P = 0.789 in difficult airway). The mean intubation time in difficult airway setting was shorter when the manikin was put into ramped position (28.3 s vs. 38.4 s, P = 0.134). The ramped position improved the glottic view in the difficult airway setting ( P = 0.017). More intubators preferred to place the manikin into a ramped position during difficult airway setting (67%, P = 0.007). Experienced male intubators performed better in normal airway scenarios, whereas Accident and Emergency Department fellows performed better in difficult airway scenarios. Conclusion: The ramped position improves glottic view and operator ease when intubating a simulated difficult airway.

Low skill fibreoptic intubation using i-gel™ and air-Q™ in simulated difficult airways: A randomised study in manikin and in patients

Background:Fibreoptic intubation via a supraglottic device (SAD) is ‘low skill fibreoptic intubation’ (LSFOI). ‘Standard’ second generation SADs (i-gelTM) have a gastric port. ‘Specialised’ second generation SADs (air-QTM) are designed to facilitate LSFOI and have wider ventilation ports. Our hypothesis was that performance of LSFOI differs between i-gelTMand air-QTMin a manikin with a simulated difficult airway.Methods:Our primary outcome was fibreoptic intubation success rate. Our secondary outcomes included SAD insertion and LSFOI times. A difficult airway was simulated by applying a hard cervical collar to a manikin. Anaesthetists performed LSFOI serially using both SADs in a random sequence. In the manikin study, 80 anaesthetists were recruited. To test the robustness of the conclusion from our manikin study, we repeated the study in 22 anaesthetised patients. Patients were fitted with the same cervical collar and randomly allocated to either devices. We used McNemar’s statistical test to analyse our primary outcome of successful intubations and paired nominal data. A Wilcoxon signed-ranks test was used to analyse nonparametric paired data and a Mann–Whitney U test was used for unpaired data analysis where appropriate. A p-value of &lt;0.05 was considered statistically significant.Results:In the manikin study, the i-gelTMwas superior to the air-QTMfor successful tracheal intubation (98.8% vs 83.8%, respectively; p=0.002) and LSFOI times (34.0 s vs 36.0 s, respectively; p=0.012). In the patient study, LSFOI success rates were not significantly different between i-gelTMand air-QTM(100% vs 91.6%, respectively; p=0.545) but intubation times were shorter (52.5 s vs 60.0 s, respectively; p=0.036).Conclusion:In conclusion, we obtained LSFOI success rates for the i-gelTMor air-QTMof 98.8% and 83.8% respectively in a manikin; and 100% and 91.6% respectively in patients. It is in fact ‘low skill’ as many participants were successful despite no prior experience with LSFOI. The i-gelTMis superior for LSFOI compared with the air-QTM. This is despite being a ‘standard’ second generation SAD as compared to a ‘specialised’ second generation SAD (air-QTM).Trial Registration:The manikin and patient studies were conducted after being approved by the SingHealth Centralised Institutional Review Board (CRB reference number 2014/2039 and 2016/2069, respectively). The patient study was registered at ClinicalTrials.gov (ID: NCT02663843).

The impact of respiratory protective equipment on difficult airway management: a randomised, crossover, simulation study.

SummaryThe current international COVID‐19 health crisis underlines the importance of adequate and suitable personal protective equipment for clinical staff during acute airway management. This study compares the impacts of standard air‐purifying respirators and powered air‐purifying respirators during simulated difficult airway scenarios. Twenty‐five anaesthetists carried out four different standardised difficult intubation drills, either unprotected (control), or wearing a standard or a powered respirator. Treatment times and wearer comfort were determined and compared. In the wearer comfort evaluation form, operators rated mobility, noise, heat, vision and speech intelligibility. All anaesthetists accomplished the treatment objectives of all study arms without adverse events. Total mean (SD) intubation times for the four interventions did not show significant differences between the powered and the standard respirator groups, being 16.4 (8.6) vs. 19.2 (5.2) seconds with the Airtraq™; 11.4 (3.4) vs. 10.0 (2.1) seconds with the videolaryngoscope; 39.2 (4.5) vs. 40.1 (4.8) seconds with the fibreoptic bronchoscope scope; and 15.4 (5.7) vs. 15.1 (5.0) seconds for standard tracheal intubation by direct laryngoscopy, respectively. Videolaryngoscopy allowed the shortest intubation times regardless of the respiratory protective device used. Anaesthetists rated heat and vision significantly higher in the powered respirator group; however, noise levels were perceived to be significantly lower than in the standard respirator group. We conclude that standard and powered respirators do not significantly prolong simulated advanced intubation procedures.

A randomized comparative study of Airtraq®, McCoy and Macintosh laryngoscopes for endotracheal intubation in patients with simulated difficult airway using a rigid cervical neck collar in elective surgeries under general anaesthesia

Laryngoscopy in patients with suspected neck injuries has one goal: sufficient laryngeal exposure with least cervical spine movement. This is achieved by either Manual In-line Stabilisation (MILS), a forehead tape or rigid cervical collars. Cervical collars reduce movements of spine and also mouth opening leading to difficult direct laryngoscopy. This is due to difficulty in aligning the oro-pharyngo-laryngeal axes. The laryngoscope giving best glottic view with least cervical spine movement in the shortest time would be most ideal. We intend to compare Airtraq, McCoy and Macintosh laryngoscopes in terms of intubation time and Cormack-Lehane glottic view in patients undergoing elective surgeries with simulated neck immobilization using rigid cervical collar.: Following approval from Institutional Ethical Committee, 90 consenting patients, aged 18-65years were assigned into three groups by random sampling (Serially numbered Opaque Sealed Envelope), namely Group A (Airtraq), M (McCoy) or C (Macintosh). Intubation time, Intubation difficulty scale (IDS) and Modified Cormack-Lehane grading were noted.: Mean intubation time was 27.2sec(± 6.47), 40.2sec (± 12.36) and 33.10sec (± 23.05) for Airtraq, McCoy and Macintosh respectively(p-value 0.00 7). IDS values were 0,3 and 2 respectively(P&amp;#60; 0.0001). Cormack Lehane glottic view was 2 for Macintosh and McCoy and 1 for Airtraq, respectively (P&amp;#60; 0.0001).Airtraq improves ease of intubation significantly when compared to McCoy and Macintosh blade with shorter intubation time and IDS Score, in patients with simulated difficult airway using neck immobilization.

Comparison of C-MAC D-blade videolaryngoscope and McCoy laryngoscope efficacy for nasotracheal intubation in simulated cervical spinal injury: a prospective randomized comparative study

BackgroundImmobilization with cervical spine worsens endotracheal intubation condition. Though various intubation devices have been demonstrated to perform well in oral endotracheal intubation, limited information is available concerning nasotracheal intubation (NTI) in patients with cervical spine immobilization. The present study compared the performance of the C-MAC D-Blade videolaryngoscope with the McCoy laryngoscope for NTI in patients with simulated cervical spine injuries.MethodsThis was a prospective, randomized, controlled, study done in a tertiary hospital. Ninety-five patients requiring NTI were included in data analysis: McCoy group (group M, n = 47) or C-MAC D-Blade videolaryngoscope group (group C, n = 48). A Philadelphia neck collar was applied before anesthetic induction to immobilize the cervical spine. Single experienced anesthesiologist performed NTI. The primary outcome was duration of intubation divided by three steps: nose to oropharynx; oropharynx into glottic inlet; and glottic inlet to trachea. Secondary outcomes included glottic view as percentage of glottis opening (POGO) score and Cormack-Lehance (CL) grade, modified nasal intubation-difficulty scale (NIDS) rating, hemodynamic changes before and after intubation, and complications.ResultsTotal intubation duration was significantly shorter in group C (39.5 ± 11.4 s) compared to group M (48.1 ± 13.9 s). Group C required significantly less time for glottic visualization and endotracheal tube placement in the trachea. More patients in group C had CL grade I and higher POGO scores (P < 0.001, for both measures). No difficulty in NTI (modified NIDS = 0) was more in group C than group M. Hemodynamic changes and incidence of complications were comparable between groups.ConclusionThe C-MAC D-Blade videolaryngoscope is an effective tool for NTI in a simulated difficult airway, which improves glottic visualization and shortens intubation time relative to those with McCoy laryngoscope.Trial registrationClinical Research Information Service of the Korea National Institute of Health, Identification number: KCT 0004535, Registered December 10, 2019, Retrospectively registered, http://cris.nih.go.kr.

Optimising remote site airway management kit dump using the SCRAM bag\u2014a randomised controlled trial

BackgroundEmergency airway management may be required at any hospital location. Remote site management is associated with increased airway morbidity and mortality. Poor planning and interrupted workflow are significant contributors. Equipment may be unfamiliar, difficult to locate or inadequate.The SCRAM (Structured CRitical Airway Management) bag aims to provide a portable, structured and reproducible approach to airway management preparation. We hypothesised that SCRAM bag use reduces equipment preparation time, the rate of error and operator cognitive load.MethodsFifty experienced anaesthetists were randomised into two groups and asked to prepare (kit dump) for and manage a simulated remote site difficult airway scenario. The control group (n = 25) used a standard resuscitation trolley while the experimental group used the SCRAM bag (n = 25). The primary outcome was time taken to kit dump completion (seconds). Secondary outcomes were the number of errors and self-reported difficulty (100 mm visual analogue scale).ResultsUsing the SCRAM bag, a 29% reduction in kit dump time (111.7 ± 29.5 vs 156.7 ± 45.1, p = 0.0001) was noted. Participants using the SCRAM bag reported it to be less challenging to use (18.36 ± 16.4 mm vs 50.64 ± 22.9 mm, p < 0.001), and significantly fewer errors were noted (1 (IQR 1–3) vs 8 (IQR 5–9), p = 0.03) (87.5% reduction in the total number of errors).ConclusionThe SCRAM bag facilitates a quicker, less challenging kit dump with significantly fewer errors. We propose that this would reduce delay to airway management, reduce cognitive load and provide an improved capability to manage anticipated and unanticipated airway events.

Comparing the use of intubating adjuncts to video laryngoscopy in a simulated difficult airway.

Comparing the use of intubating adjuncts to video laryngoscopy in a simulated difficult airway.

Innovation in low-cost videolaryngoscopy: Intubator V1-Indirect compared with Storz C-MAC in a simulated difficult airway

Innovation in low-cost videolaryngoscopy: Intubator V1-Indirect compared with Storz C-MAC in a simulated difficult airway

Assessment of Success and Ease of Insertion of ProSeal™ Laryngeal Mask Airway versus I-gel™ Insertion by Paramedics in Simulated Difficult Airway Using Cervical Collar in Different Positions in Manikins.

Background:Tracheal intubation, a critical intervention, performed by paramedics for airway management in trauma, has an unacceptably low success rate due to difficult airway, restricted access, and inexperience. Thus, the use of supraglottic devices to achieve ventilation has gained popularity.Aims:We aimed to compare the success rate, time to achieve ventilation, and ease of insertion of two popular supraglottic devices, ProSeal™ laryngeal mask airway (PLMA) and I-gel™, in simulated difficult airway with limited access in manikins in different positions which were supine, head against the wall, and sitting position like in car seat.Settings and Design:This was a prospective interventional study.Materials and Methods:After a brief training, 35 paramedics were asked to insert I-gel™ and PLMA in a manikin with cervical collar in 3 positions: head end free (Group A), head against the wall (Group B), and sitting position (Group C), to simulate difficult airway. Success rate and time to achieve ventilation in each position were noted. Each participant graded ease of insertion.Statistical Analysis:Statistical analysis was performed using SPSS 24.0. Categorical variables were analyzed using a Pearson's Chi-square test. Continuous variables were analyzed using the Kolmogorov–Smirnov test. If there was a normal distribution, a paired t-test was performed. Otherwise, a Wilcoxon signed-rank test was performed. P < 0.05 was considered statistically significant.Results:Success rate with I-gel™ was significantly higher than PLMA, 91% versus 77% in Group A, 100% versus 88% in Group B, and 100% versus 74% in Group C. Time to achieve ventilation was shorter with I-gel™ than PLMA, 8.9 versus 15 s in Group A (P < 0.001), 13.1 versus 21.3 s in Group B (P < 0.01), and 18.5 versus 30.3 s in Group C (P < 0.001).Conclusion:I-gel™ can be an effective device to achieve ventilation in difficult airway with limited access in trauma. More studies are required to validate its success and safety.