Difficult Endotracheal Intubation Research Articles

Utility of videolaryngoscopy for diagnostic and therapeutic interventions in head and neck surgery.

Videolaryngoscopy is commonly used by anesthesiologists to manage difficult airways. Recently otolaryngologists have reported use in select procedures; to date there is limited evaluation in head and neck surgery. Patients who underwent direct laryngoscopy (DL) with use of GlideScope videolaryngoscopy (GVL) were retrospectively identified from a tertiary care Veterans Affairs hospital. GVL was used to assist or replace traditional laryngoscopes for diagnostic and therapeutic procedures. Nineteen patients (48-83 years old) underwent 21 procedures. Difficult endotracheal intubation was reported in 53% of patients. GVL replaced traditional DL in 76% of cases, assisted evaluation prior to traditional DL in 10%, and rescued failed traditional DL in 14%. No complications occurred. Three indications for GVL were identified. GVL was safe in our experience and provides unique benefits in selected scenarios in head and neck surgery. Otolaryngologists can consider videolaryngoscopy as a complement to traditional DL.

Challenging the Traditional Definition of a Difficult Intubation: What is Difficult?

(Anesth Analg. 2019;128(3):584–586. Doi:10.1213/ANE.0000000000003886) While video laryngoscopy (VL) has brought substantial changes to the practice of airway management, the way anesthesiologists define a “difficult intubation” has not been altered accordingly. The American Society of Anesthesiologists has defined a “difficult airway” as “the clinical situation in which a conventionally trained anesthesiologist experiences difficulty with facemask ventilation of the upper airway, difficulty with intubation, or both,” and also has set forth clear, separate definitions of difficult endotracheal intubation and difficult laryngoscopy. These latter 2 definitions can be subjective and interpreted inconsistently, however, and varied devices and contexts make these definitions even more ambiguous. A patient may not be labeled as a difficult intubation by one provider, but labeled difficult by another provider in a different setting. A study by Lewis and colleagues showed when VL was used, there were significantly fewer failed intubations compared with direct laryngoscopy (DL) alone. However, VL has not outdone the success rate of awake fiberoptic intubations in patients with perceived difficult airway. VL is available in >90% of operating rooms in British National Health Service hospitals according to a survey by Cook and Kelly, and some studies have recommended the use of VL become standard of care for both routine and difficult intubations.

Factors Predicting Difficult Endotracheal Intubation.

Factors Predicting Difficult Endotracheal Intubation.

VALIDITY OF CERTAIN BEDSIDE TESTS IN PREDICTING DIFFICULT ENDOTRACHEAL INTUBATION

Unexpected difficult endotracheal intubation remains the main concern of anesthesiologists. This study aimed to compare validity and role of 7 bedside techniques of assessment used in predicting difficult intubation. This prospective study included 80 patients scheduled for surgery. Before induction of anesthesia, bedside tests for predicting difficult intubation were done, these tests are: Prayer sign, Thyromental distance, Mallampati test, The inter incisor distance, Palm print test, Upper lip bite test, and Wilson scoring system. During induction of anesthesia, laryngoscopic view was evaluated. Values for each test were calculated and compared. The results showed that, the highest sensitivity (62.5%) was for Mallampati and thyromental distance but despite that, they differed in their specificity and predictive values. Upper lip bite was 12.5% sensitive but had one of the highest specificity alongside with Mallampati test. Thyromental distance was 34.7% specific. Mallampati classes of more than class I was strongly associated with difficult intubation. The mouth gap of more than 4 cm was marginally associated with difficult intubation. The predictor Wilson showed a significant association with difficult intubation if the score exceeded 3.5. The upper lip bite of more than class I was slightly associated with difficult intubation. In conclusion, Mallampati classification and thyromental distance are superior to other available tests to predict difficult intubation, performing these two tests alone is relatively adequate to predict intubation difficulty. Keywords: Difficult endotracheal intubation, The inter incisor distance, Wilson scoring system, Mallampati test, Palm print test, Prayer sign, Upper lip bite test, and Thyromental distance.

Intractable Course of a Submandibular Abscess Following Difficult Endotracheal Intubation : A Case Report

Intractable Course of a Submandibular Abscess Following Difficult Endotracheal Intubation : A Case Report

Challenging the Traditional Definition of a Difficult Intubation: What Is Difficult?

Challenging the Traditional Definition of a Difficult Intubation: What Is Difficult?

Comparison of Airtraq and Macintosh laryngoscope for Easy and Difficult Endotracheal Intubation in Adults

Introduction- Direct laryngoscopy and orotracheal intubation are essentially done using one of the curved or straight blade laryngoscopes. Most common curved blade laryngoscope is the Macintosh blade, which is the gold standard for tracheal intubation since 1940’s. The Airtraq (Prodol, Meditec, Vizcaya, Spain) is a novel optical indirect laryngoscope designed to facilitate tracheal intubation in patients with both normal and difficult upper airway anatomy. This study is conducted to compare the conventional (Macintosh) laryngoscope with newer Airtraq laryngoscope to assess ease and time taken for intubation, complications encountered in the form of dental clicks and lip lacerations.Materials and Methods- Patients were randomly allocated in two groups, comprising 60 patients each, group I (Macintosh).and group II (Airtraq). On the basis of airway assessment study groups was divided into easy and difficult airway categories. After induction of general anesthesia, tracheal intubation was attempted with the Airtraq or the Macintosh laryngoscope asper group. Primary end points were overall success rate of tracheal intubation and data was analysed in SPSS 19.0 using chi-square test , unpaired t test.Results- In present study it was observed that time taken for successful intubation was significantly less (p=<0.001) in airtraq group (14.73 +2.50 sec) and (20.10+1.85sec) as compared to macintosh group in easy and difficult airway category. Intubation difficulty score was found to be significantly lower in airtraq group as compared to airtraq group in both airway categories. Cormack Lehane scale was found to significantly lower in airtraq group as compared to macintosh group in both airway categories.

Surgically assisted caudal anesthesia in a case of Ankylosing Spondylitis-An innovative approach.

Anticipated difficult endotracheal intubation and impossibility of conventional methods of neuraxial blocks in Ankylosing Spondylitis (AS) led to our search for an alternative technique of regional anesthesia for total hip replacement surgery in such a patient. The approach undertaken was, after infiltration of the area with a local anesthetic drug, an orthopedic surgeon drilled the posterior wall of sacral hiatus and surgically created a small opening on it. A nerve stimulator needle was then introduced through this opening to get muscle twitches of the great toe, which helped in identification of the sacral epidural space. 30 ml of 0.5% injection ropivacaine was then deposited in this extradural space. Motor and sensory blocks developed within 10 minutes. The novel approach of surgically assisted drilling of the posterior wall of sacral hiatus may be established as an alternative approach to the classical caudal anesthesia when other alternatives fail.

Use of laryngeal mask after repeated endotracheal intubation failure in a patient with tracheobronchopathia osteochondroplastica: case report

We report a case of difficult endotracheal intubation in a patient with tracheobronchopathia osteochondroplastica. A 65-year-old man was scheduled to undergo ulnar nerve decompression and ganglion excisional biopsy under general anesthesia. During induction of general anesthesia, an endotracheal tube could not be advanced through the vocal cords due to resistance. A large number of nodules were identified below the vocal cords using a Glidescope® video-laryngoscopy, and fiberoptic bronchoscopy revealed irregular nodules on the surface of the entire trachea and the main bronchus below the vocal cords. Use of a small endotracheal tube was attempted and failed. a laryngeal mask airway (LMA Supreme ™) rather than further intubation was successfully used to maintain the airway.

Difficult Intubation in Patients with Carcinoma of the Larynx and Hypopharynx

Introduction: ASA defines difficult intubation as tracheal intubation which requires more than three attempts with direct laryngoscopy. In a major study including 3325 patients, three or more attempts for direct laryngoscopy were needed in 1,9%, and intubation failure was observed in 0,1%. The Aim of the study is to determine difficult intubation rates in patients with laryngeal and hypopharyngeal carcinoma. Materials and Methods: A prospective cohort study including 100 patients undergoing microlaryngeal surgery in the Department of Otorhinolaryngology at the University Hospital „Queen Giovanna“ – ISUL, Sofia, in the period 2014-2017. Results and discussion: Difficult intubation is observed in 8 patients (8%). Impossible intubation is observed in 12 patients (12%). The study showed that the major factor leading to difficult endotracheal intubation in patients with carcinoma of the larynx and hypopharynx is the laryngeal obstruction caused by the malignant process. Conclusion: difficult and impossible intubation rates in patients undergoing laryngectomies are higher than in the common population due to the obstruction caused by the carcinoma.

Comparison of etomidate and sodium thiopental for induction during rapid sequence intubation in convulsive status epilepticus: A retrospective single-center study

PurposeFew outcome data are available about morbidity associated with endotracheal intubation modalities in critically ill patients with convulsive status epilepticus. We compared etomidate versus sodium thiopental for emergency rapid sequence intubation in patients with out-of-hospital convulsive status epilepticus. MethodsPatients admitted to our intensive care unit in 2006–2015 were studied retrospectively. The main outcome measure was seizure and/or status epilepticus recurrence within 12 h after rapid sequence intubation. ResultsWe included 97 patients (60% male; median age, 59 years [IQR, 48–70]). Median time from seizure onset to first antiepileptic drug was 60 min [IQR, 35–90]. Reasons for intubation were coma in 95 (98%), acute respiratory distress in 18 (19%), refractory convulsive status epilepticus in 9 (9%), and shock in 6 (6%) patients; 50 (52%) patients had more than one reason. The hypnotic drugs used were etomidate in 54 (56%) and sodium thiopental in 43 (44%) patients. Seizure and/or status epilepticus recurred in 13 (56%) patients in the etomidate group and 11 patients (44%) in the sodium thiopental group (adjusted common odds ratio [aOR], 0.98; 95%CI, 0.36–2.63; P = 0.97). The two groups were not significantly different for proportions of patients with hemodynamic instability after intubation (aOR, 0.60; 95%CI, 0.23–1.58; P = 0.30) or with difficult endotracheal intubation (OR, 1.28; 95% CI 0.23 to 7.21; P=0.77). ConclusionsOur findings argue against a difference in seizure and/or status epilepticus recurrences rates between critically ill patients with convulsive status epilepticus given etomidate vs. sodium thiopental as the induction agent for emergency intubation.

Comparison of Nasal Intubations by GlideScope With and Without Bougie Guide in Patients Who Underwent Maxillofacial Surgeries: Randomized Clinical Trial: Pourfakhr P, Ahangari A, Etezadi F, et al. Anesth Analg. 2018;126:1641-5

The establishment of airway is a vital component of patient life support and as such providers must be versatile in multiple intubation techniques. Nasotracheal intubation (NTI) in the operating room can be the preferred method of intubation particularly during facial surgeries or patients with oral pathology that limits typical endotracheal intubation (ETI). The Gum Elastic Bougie (GEB) has been a valuable tool for first pass and difficult ETI and several small studies have suggested it may have a role in NTI.

Case Report of a Displaced Tooth in the Palate Causing a Difficult Endotracheal Intubation in a Patient with Treacher-Collins Syndrome

Case Report of a Displaced Tooth in the Palate Causing a Difficult Endotracheal Intubation in a Patient with Treacher-Collins Syndrome

Comparison of Modified Mallampati Test and Upper Lip Bite Test in Prediction of Difficult Endotracheal Intubation: A Prospective Study

Comparison of Modified Mallampati Test and Upper Lip Bite Test in Prediction of Difficult Endotracheal Intubation: A Prospective Study

Anesthesia management in an adult patient with sleep-disordered breathing and difficult intubation: A case report

Obstructive sleep apnea may be associated with numerous comorbidities and perioperative complications. Poor laryngeal anatomy visualization can be a cause of failed tracheal intubation after multiple attempts in patients with sleep-disordered breathing due to the underlying adenoid enlargement. We present a case of difficult endotracheal intubation in a 52-year-old menopausal female patient posted for tonsillectomy with adenoid resection with a history of snoring and difficulty in breathing while asleep. A thorough preoperative assessment focusing on history and investigating obstructive sleep apnea, and preparing and planning for difficult tracheal intubation in such patients can lead to successful endotracheal intubation inside the operation theater.

Comparison of Upper Lip Bite Test and Ratio of Height to Thyromental Distance with Other Airway Assessment Tests for Predicting Difficult Endotracheal Intubation.

Background and Aims:Unanticipated difficult intubation or the failed intubation in operating room and in emergency department is an imperative source of anesthesia-related patient's mortality. The aim of this study is to compare the predictive value of upper lip bite test (ULBT) and ratio of height to thyromental distance (RHTMD) with other commonly used preoperative airway assessment tests for predicting difficult intubation in Indian population.Materials and Methods:In this prospective, single-blinded observational study, 260 adult patients of either sex, belonging to American Society of Anesthesiologists physical Status I and II undergoing elective surgical procedure under general anesthesia were included in the study. ULBT, RHTMD, inter-incisor gap, modified Mallampati grade, horizontal length of the mandible, head and neck movements, sternomental distance, and TMD were assessed preoperatively and correlated with Cormack and Lehane's grading during laryngoscopy under anesthesia. Statistical analysis was done by Chi-square and Fisher's exact test.Results:ULBT and RHTMD had highest sensitivity (66.7% and 63.3%), specificity (99.1% and 89.6%), positive predictive value (90.9% and 44.2%), and negative predictive value (96.9% and 95.0%), respectively, when compared to other parameters in predicting difficult airway.Conclusion:ULBT and RHTMD may be used as a simple bedside airway assessment tools for prediction of difficult intubation.

Nondepolarizing muscle relaxant improves direct laryngoscopy view with no effect on face mask ventilation

Difficult or impossible face mask ventilation complicated with difficult tracheal intubation during anesthesia induction occurs in 0.4% of adult anesthesia cases, possibly leading to life-threatening complications. Because of such catastrophes, muscle relaxants have been recommended to be administered after confirming adequate face mask ventilation without a solid scientific validation of this principal. In this observational study, the ease of ventilation and the scores of direct laryngoscopy views before and after administration of cisatracurium were assessed in ninety young healthy adults, without anesthetic risks and without foreseen difficult intubation and who were scheduled for general elective surgeries. Before muscle relaxation, 43 patients (48%) were Cormack Grade I, while the remaining 47 patients (52%) were either Cormack Grade II (28 patients, 31%) or Cormack Grade II (19 patients, 21%). Following muscle relaxation with cisatracurium, the number of patients with Cormack Grade I significantly increased from 43 patients (48%) to 65 patients (72%) (p=0.0013). Only 1 patient out of 19 patients (5%) improved his Cormack grade from Grade III to Grade I while 16 out 19 patients (84%) improved their Cormack grade from Grade III to Grade II after the use of cisatracurium. The quality of face mask ventilation did not differ with and without muscle relaxants in all patients. The use of cisatracurium in healthy young adults undergoing general elective surgeries with no anticipated difficult endotracheal intubation had no effect on the quality of face mask ventilation despite resulting in a quantifiable improvement in the laryngeal view.

Successful tracheal intubation with video laryngoscope when awake fiberoptic bronchoscopy failed in a patient with hypopharyngeal mass

Video laryngoscope is one of best alternative in managing difficult airways. Our patient presented with left side neck pain and hoarseness of voice for three months, dysphagia to solids for two months. Computed tomography revealed large hypopharyngeal mass and a diagnosis of carcinoma of hypopharynx was made. As endoscopic Ryle’s tube insertion by gastroenterologist was unsuccessful so he was posted for Feeding jejunostomy under general anaesthesia. We anticipated difficult endotracheal intubation. Our first attempt to secure airway with awake fiberoptic bronchoscopic intubation was unsuccessful. Using an alternative method with bougie and video laryngoscopy, the trachea was successfully intubated. In rare clinical scenario fiberoptic bronchoscopic intubation may fail, hence we need to be prepared with the backup plan for airway management. A video laryngoscope might be useful in such situations.

Acromegaly discovered during a routine out-patient surgical procedure: a case report

BackgroundAcromegaly is a rare syndrome in which there is unregulated hypersecretion of growth hormone. The anesthetic management of patients with this disorder is particularly challenging due to pre-existing cardiovascular and respiratory dysfunction, as well as recognized difficulties with airway management. Because of the insidious progression of the disease and the presence of nonspecific signs and symptoms, diagnosis is often made late when characteristic acromegalic features become apparent.Case presentationWe report the management of a 35-year-old African American man with previously undiagnosed acromegaly, who underwent a general anesthetic for same day surgery. Subtle physical features and difficult endotracheal intubation raised our suspicion for the diagnosis of acromegaly. Following an uncomplicated postoperative course he underwent workup for the disease, which was confirmed. In addition, brain magnetic resonance imaging showed a pituitary adenoma. A subsequent transsphenoidal hypophysectomy was performed successfully.ConclusionsThis case underscores the notable absence of recognizing the clinical presentation of acromegaly in this patient by his primary care physician, and the value of thorough history taking, vigilance, and observation in making a new diagnosis that has the potential to alter a patient’s health care and mitigate impending morbidity and/or mortality.

Derivation and Validation of The Prehospital Difficult Airway IdentificationTool (PreDAIT): A Predictive Model for Difficult Intubation.

IntroductionEndotracheal intubation (ETI) in the prehospital setting poses unique challenges where multiple ETI attempts are associated with adverse patient outcomes. Early identification of difficult ETI cases will allow providers to tailor airway-management efforts to minimize complications associated with ETI. We sought to derive and validate a prehospital difficult airway identification tool based on predictors of difficult ETI in other settings.MethodsWe prospectively collected patient and airway data on all airway attempts from 16 Advanced Life Support (ALS) ground emergency medical services (EMS) agencies from January 2011 to October 2014. Cases that required more than two ETI attempts and cases where an alternative airway strategy (e.g. supraglottic airway) was employed after one unsuccessful ETI attempt were categorized as “difficult.” We used a random allocation sequence to split the data into derivation and validation subsets. Using backward elimination, factors with a p<0.1 were included in the multivariable regression for the derivation cohort and then tested in the validation cohort. We used this model to determine the area under the curve (AUC), and the sensitivity and specificity for each cut point in both the derivation and validation cohorts.ResultsWe collected data on 1,102 cases with 568 in the derivation set (155 difficult cases; 27%) and 534 in the validation set (135 difficult cases; 25%). Of the collected variables, five factors were predictive of difficult ETI in the derivation model (adjusted odds ratio, 95% confidence interval [CI]): Glasgow coma score [GCS] >3 (2.15, 1.19–3.88), limited neck movement (2.24, 1.28–3.93), trismus/jaw clenched (2.24, 1.09–4.6), inability to palpate the landmarks of the neck (5.92, 2.77–12.66), and fluid in the airway such as blood or emesis (2.25, 1.51–3.36). This was the most parsimonious model and exhibited good fit (Hosmer-Lemeshow test p = 0.167) with an AUC of 0.68 (95% CI [0.64–0.73]). When applied to the validation set, the model had an AUC of 0.63 (0.58–0.68) with high specificity for identifying difficult ETI if ≥2 factors were present (87.7% (95% CI [84.1–90.8])).ConclusionWe have developed a simple tool using five factors that may aid prehospital providers in the identification of difficult ETI.