Difficult Tracheal Intubation Research Articles

Anticipated Difficult Tracheal Intubation: Comparison between conventional laryngoscope (Macintosh) and video laryngoscope TrueView EVO2

Context: In patients with anticipated difficult airway, it is difficult to align the oropharyngolaryngeal axis to facilitate intubation by conventional laryngoscopy, which leads to failed intubation. The TruView EVO 2 laryngoscope is a device with a unique blade that provides an optical view around the corner. The blade is a modified laryngoscope blade incorporating an unmagnified optic side port with anterior fraction of 42΀ in the line of sight allowing indirect tracheal intubation. Aim: The aim of the study was to compare TrueView blade with Macintosh blade with respect to the (view of the glottis by (Cormack-Lehane grading); Time for tracheal Intubation, Attempts required for intubation, maneuvers to optimize the laryngeal view and success rate of intubation); Settings and Design: It was a prospective, randomized controlled single blind clinical study. Materials and Methods: Seventy ASA grade I and II, Mallampatti Grading (MPG), III and IV patients posted for elective surgery with restricted neck mobility such as post-burn contracture neck, cervical spine surgeries divided into Group 1-35 patients (Trueview) and Group 2-35 patients (Macintosh). All intubation was done by an expert anesthesiologist. Statistical Analysis: Tests used were Mann-Whitney U test, two independent sample t-tests, Chi-square test, and Fischer's exact t-test. Results: Cormack-Lehane Grade I was seen in 62.85% and O in Group 1 and Group 2, respectively. Grade II was seen in 37.14% and 28.57% in Group 1 and Group 2, respectively, and Grade III in 0 and 71.42% in Groups 1 and 2, respectively, which was statistically significant. Thus EVO 2 improved the view of glottis by 2 Grades. Both the techniques were comparable as far as time is concerned. A 94.2% patients in Group 1 intubated in 1 st attempt, 5% needed 2 nd attempt, whereas in Group 2 72.7% patients were intubated in 1 st attempt and 27.2% in 2 nd attempt. Maneuver BURP required more with conventional laryngoscopy. Success rate in Group 1 was 100% and in Group 2 it was 94.2%. Conclusion: The use of TrueView in patients with anticipated difficult airway considerably improved the view of glottis. With adequate experience, the number of attempts may be reduced and maneuver required for securing airway successfully could be optimized.

Intubation with Storz DCI videolaryngoscope and Truview EVO2 videolaryngoscope: in patients with suspected difficult tracheal intubation

Intubation with Storz DCI videolaryngoscope and Truview EVO2 videolaryngoscope: in patients with suspected difficult tracheal intubation

Diagnostic accuracy of anaesthesiologists' prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database.

Both the American Society of Anesthesiologists and the UK NAP4 project recommend that an unspecified pre-operative airway assessment be made. However, the choice of assessment is ultimately at the discretion of the individual anaesthesiologist. We retrieved a cohort of 188064 cases from the Danish Anaesthesia Database, and investigated the diagnostic accuracy of the anaesthesiologists' predictions of difficult tracheal intubation and difficult mask ventilation. Of 3391 difficult intubations, 3154 (93%) were unanticipated. When difficult intubation was anticipated, 229 of 929 (25%) had an actual difficult intubation. Likewise, difficult mask ventilation was unanticipated in 808 of 857 (94%) cases, and when anticipated (218 cases), difficult mask ventilation actually occurred in 49 (22%) cases. We present a previously unpublished estimate of the accuracy of anaesthesiologists' prediction of airway management difficulties in daily routine practice. Prediction of airway difficulties remains a challenging task, and our results underline the importance of being constantly prepared for unexpected difficulties.

Anaesthetic implications in Von Recklinghausen disease: A case report

Von Recklinghausen disease or neurofibromatosis Type I (NF1) is an autosomal dominant disease with a wide spectrum of clinical manifestations. Neurofibromas are the characteristic lesions. This disorder is associated with important anaesthetic considerations, mainly when neurofibromas occur in the oropharynx and larynx, leading to difficult laryngoscopy and tracheal intubation. We describe the anaesthetic management of a patient with NF1 under general anaesthesia for facial neurofibroma excision. We performed a brief review of the literature with the aim of optimizing the anaesthetic management and reducing the number of complications associated with the systemic manifestations of this syndrome.

Implicaciones anestésicas en la enfermedad de Von Recklinghausen

Von Recklinghausen disease or neurofibromatosis Type I (NF1) is an autosomal dominant disease with a wide spectrum of clinical manifestations. Neurofibromas are the characteristic lesions. This disorder is associated with important anaesthetic considerations, mainly when neurofibromas occur in the oropharnyx and larynx, leading to difficult laryngoscopy and tracheal intubation. We describe the anaesthetic management of a patient with NF1 under general anaesthesia for facial neurofibroma excision. We performed a brief review of the literature with the aim of optimizing the anaesthetic management and reduce the number of complications associated with the systemic manifestations of this syndrome.

Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways.

Emergency and difficult tracheal intubations are hazardous undertakings where successive laryngoscopy–hypoxaemia–re-oxygenation cycles can escalate to airway loss and the ‘can't intubate, can't ventilate’ scenario. Between 2013 and 2014, we extended the apnoea times of 25 patients with difficult airways who were undergoing general anaesthesia for hypopharyngeal or laryngotracheal surgery. This was achieved through continuous delivery of transnasal high-flow humidified oxygen, initially to provide pre-oxygenation, and continuing as post-oxygenation during intravenous induction of anaesthesia and neuromuscular blockade until a definitive airway was secured. Apnoea time commenced at administration of neuromuscular blockade and ended with commencement of jet ventilation, positive-pressure ventilation or recommencement of spontaneous ventilation. During this time, upper airway patency was maintained with jaw-thrust. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) was used in 15 males and 10 females. Mean (SD [range]) age at treatment was 49 (15 [25–81]) years. The median (IQR [range]) Mallampati grade was 3 (2–3 [2–4]) and direct laryngoscopy grade was 3 (3–3 [2–4]). There were 12 obese patients and nine patients were stridulous. The median (IQR [range]) apnoea time was 14 (9–19 [5–65]) min. No patient experienced arterial desaturation < 90%. Mean (SD [range]) post-apnoea end-tidal (and in four patients, arterial) carbon dioxide level was 7.8 (2.4 [4.9–15.3]) kPa. The rate of increase in end-tidal carbon dioxide was 0.15 kPa.min−1. We conclude that THRIVE combines the benefits of ‘classical’ apnoeic oxygenation with continuous positive airway pressure and gaseous exchange through flow-dependent deadspace flushing. It has the potential to transform the practice of anaesthesia by changing the nature of securing a definitive airway in emergency and difficult intubations from a pressured stop–start process to a smooth and unhurried undertaking.

Delivery of anesthesia and complications for children with Fraser syndrome: a review of 125 anesthetics.

To perform a retrospective, anesthesia case note review of patients with Fraser syndrome. To identify the perioperative and postoperative anesthetic management and complications in this patient group. Fraser syndrome is a rare, autosomal recessively inherited disorder characterized by cryptophthalmos, cutaneous syndactyly, and ambiguous genitalia. It also has variable association with cardiac, laryngeal, tracheal, and gastrointestinal abnormalities. Children with Fraser syndrome present for a variety of surgical and radiological procedures, and there are a number of single case reports in the literature. A retrospective case note review was undertaken on 10 children with Fraser syndrome who presented to our institution over a 30-year period. Analysis of the medical notes and general anesthetic records was undertaken, and the conduct of anesthesia, spectrum of disease, genetic markers, and perioperative complications were recorded. There were a total of 125 procedures performed under general anesthesia during this period. There were a total of ten anesthetic complications in the review, all related to management of the airway. There were two accidental extubations, five recorded incidents of airway obstruction (which were relieved with continuous positive airway pressure (CPAP)) and one posttracheostomy airway bleed. One child was a difficult intubation requiring an ID 2.5mm oral endotracheal tube (ETT), and one child was an impossible intubation that required an emergency tracheostomy to secure the airway. There was a low incidence of complications with this group of patients. However, there is a relatively high incidence of difficult or impossible tracheal intubation (20%) due to glottic stenosis and one patient required an emergency tracheostomy despite no previous clinical evidence of airway narrowing.

Incidence and associated factors of difficult tracheal intubations in pediatric ICUs: a report from National Emergency Airway Registry for Children: NEAR4KIDS.

To evaluate the incidence and associated risk factors of difficult tracheal intubations (TI) in pediatric intensive care units (PICUs). Using the National Emergency Airway Registry for Children (NEAR4KIDS), TI quality improvement data were prospectively collected for initial TIs in 15 PICUs from July 2010 to December 2011. Difficult pediatric TI was defined as TIs by direct laryngoscopy which failed or required more than two laryngoscopy attempts by fellow/attending-level physician providers. A total of 1,516 oral TIs were reported with a median age of 2 years. A total of 97% of patients were intubated with direct laryngoscopy. The incidence of difficult TI was 9%. In univariate analysis, patients with difficult TI were younger [median 1 year (0-4) vs. 2 (0-8) years, p = 0.046], and had a reported history of difficult TI (22 vs. 8%, p < 0.001). Multivariate analysis showed that history of difficult airway and signs of upper airway obstruction are significantly associated with difficult TI. The advanced airway provider was more involved as a first provider in difficult TI (81 vs. 58%, p < 0.001). The presence of difficult TI was associated with higher incidence of oxygen desaturation below 80% (48 vs. 15%, p < 0.001), adverse TI associated events (53 vs. 20%, p < 0.001), and severe TI associated events (13 vs. 6%, p = 0.003). Difficult TI was reported in 9% of all TIs and was associated with increased adverse TI events. History of difficult airway and sign of upper airway obstruction were associated with difficult TIs.

Desplazamiento esofágico de un tubo endotraqueal durante la oxigenación nasofaríngea en un neonato con secuencia de Pierre Robin. Caso clínico

Conventional intubation for pulmonary management in children with a difficult airway may be very challenging even in skilled hands. Rapid advancements in respiratory care have reduced the incidence of difficult tracheal intubation and the incidence of complications have decreased accordingly. However, serious unexpected complications still occur in some patients today. Herein, we describe a syndromic newborn infant with a difficult airway who experienced migration of the endotracheal tube into the esophagus after displacement of the tube connector. We would like to share our experience and contribute to the literature with the presentation of this undesired event. To the best of our knowledge, no such complication has been reported in the neonatal literature before.

A survey of Canadian anesthesiologists' preferences in difficult intubation and "cannot intubate, cannot ventilate" situations.

The purpose of this survey was to determine the equipment that anesthesiologists prefer in difficult tracheal intubation and "cannot intubate, cannot ventilate" (CICV) situations. A questionnaire was e-mailed to members of the Canadian Anesthesiologists' Society to ascertain their preferences, experience, and comfort level with regard to their use of airway equipment in difficult intubation and CICV situations in adult patients. A Chi square test was used to analyse the data. All reported P values are two-sided. Nine hundred ninety-seven of 2,532 questionnaires (39%) were returned. In an unanticipated difficult direct laryngoscopic intubation situation, 893 of 997 (90%) respondents chose a video laryngoscope as the first-choice rescue technique, while 41 (4%) and 21 (2%) of respondents chose a flexible bronchoscope and an intubating laryngeal mask airway device, respectively. The majority of anesthesiologists had experience and were comfortable with using a flexible bronchoscope or a video laryngoscope. Regarding CICV, 294 of 955 (31%) respondents stated that they had never encountered it. Wire-guided cricothyroidotomy was chosen as the first-choice surgical airway by 375 of 955 (39%) respondents, while intravenous catheter cricothyroidotomy and "defer to tracheostomy by surgeon" were selected by 266 (28%) and 215 (23%) respondents, respectively. Seven hundred eighty-five of 997 (78%) respondents were familiar with the exact steps of the American Society of Anesthesiologists' difficult airway algorithm, while 448 (47%) had attended an airway workshop within the past five years. In a difficult intubation situation, the most frequently selected first-choice airway device was a video laryngoscope, followed by a flexible bronchoscope. In a CICV situation, the most frequently selected first-choice surgical airway technique was a wire-guided cricothyroidotomy, followed by an intravenous catheter cricothyroidotomy.

Pentax Airway Scope® vs Macintosh laryngoscope for tracheal intubation in adult patients: a systematic review and meta‐analysis

The Pentax Airway Scope(®) is a single-use optical videolaryngoscope designed to assist with difficult tracheal intubation. We systematically reviewed the efficacy of the Pentax Airway Scope with that of a conventional laryngoscope for tracheal intubation in adults with 'normal' and 'difficult' airways. We included 17 randomised controlled trials with a total of 1801 participants. We used the DerSimonian and Laird random-effects model to calculate pooled relative risk or weighted mean differences. The relative risk (95% CI) of a Cormack-Lehane grade-1 laryngeal view was 2.40 (1.76-2.49) with the Pentax Airway Scope compared with the Macintosh laryngoscope, p < 0.00001. We found no other differences between the two laryngoscopes. Despite a superior laryngeal view, the Pentax Airway Scope provides little clinical benefit over the conventional laryngoscope.

Mallampati classification without tongue protrusion can predict difficult tracheal intubation more accurately than the traditional Mallampati classification

IntroductionThe modified Mallampati classification (m-MMT) is the most popular technique for predicting difficult tracheal intubation. However, tongue protrusion may sometimes hide the oropharynx when the distance of the mouth opening is short, and this may lead to false-positive (FP) estimations of difficulty. The purpose of this study is to determine whether the Mallampati classification with no tongue protrusion (NT-MMT) can predict difficult tracheal intubation more accurately than the traditional m-MMT method. MethodsA total of 748 patients requiring endotracheal intubation were enrolled in this study. They were evaluated by m-MMT and by NT-MMT prior to surgery. After induction of general anesthesia with muscle relaxation, all patients underwent direct laryngoscopy, and the best glottic view was recorded as defined by the grading system of Cormack and Lehane. The preoperative assessment data and the intubation findings were used to determine the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the aforementioned tests in predicting difficult intubation. ResultsNT-MMT classification scored higher in all parameters than m-MMT. Similarly, the coefficient of reliability of Spearman's ρ test was higher with NT-MMT than with m-MMT. ConclusionNT-MMT is easy to perform and was more accurate in predicting difficult tracheal intubation than m-MMT.

Influence of apnoeic oxygenation in respiratory and circulatory system under general anaesthesia.

Apnoeic oxygenation is an alternative technique of oxygenation which is recommended in the consecutive oxygen administration with varying flows (2-10 lt/min) through a catheter which is positioned over the keel of the trachea. Apnoeic oxygenation maintains for a significant period of time the oxygenation of blood in breathless conditions. This technique was first applied in 1947 by Draper, Whitehead, and Spencer and it was studied sporadically by other inventors too. However, the international literature shows few studies that have examined closely apnoeic oxygenation and its effects on Hemodynamic image and the respiratory system of the human body. Recently they have begun to arise some studies which deal with the application of this technique in several conditions such as difficult tracheal intubation, ventilation of guinea pigs in campaign conditions where the oxygen supply is limited and calculable, the application of this technique in combination with the use of extracorporeal removal of carbon dioxide (CO2). All the above indicate, the clinical use of this technique.

Reducing the risk of anaesthetic complications in patients with brachycephalic obstructive airway syndrome

This article highlights the main complications that can occur when anaesthetising dogs with brachycephalic obstructive airway syndrome (BOAS) and provides clinical techniques to reduce instances of complications. Complications include obstruction of the upper airway, difficult tracheal intubation and risk of hypoxia. Some BOAS patients are also at risk of regurgitation and aspiration of gastric fluid.

気道の確保と挿管困難症 (2)挿管困難症

気道の確保と挿管困難症 (2)挿管困難症

Anesthetic experience for laparoscopic cholecystectomy in a patient with myelodysplastic syndrome with trisomy 8 mosaicism syndrome.

The trisomy 8 mosaicism syndrome (T8M) is a chromosomal disorder due to the presence of a complete extra chromosome 8 in some cells of the body. The anesthetic management of the patient may provide some problems such as a difficult tracheal intubation, cardiac malformation, hematological malignancies, mental retardation and kidney dysfunction [1,2]. This seems to be the first report on myelodysplastic syndrome patients with T8M who experienced a laparoscopic cholecystectomy under general anesthesia. A 58-year-old male patient (173 cm height and weighed 53 kg) was scheduled for preventive laparoscopic cholecystectomy due to gallstones. Recently, he was diagnosed with myelodysplastic syndrome with T8M and it was decided to perform the operation before the beginning of chemotherapy. He had undergone a percutaneous coronary intervention with drug eluting stent due to stable angina 3 months ago and had been taking dual antiplatelet therapy (aspirin and clopidogrel). The preoperative routine laboratory values showed bicytopenia, PT/aPTT prolongation and an elevation of liver enzymes. The stability of the cer vical spine was reviewed and showed a degenerative spondylosis. The findings of electrocardiography and echocardiography were normal. The patient exhibited the normal facial features. On airway examination, the thyromental distance showed 4.5 cm, the Mallampati airway classification was grade 3 and difficulties with an intubation were predicted. The blood pressure was 110/70 mmHg, heart rate was 70 beats/min and oxygen saturation was 98% before anesthesia. The patient was premedicated with intravenous glycopyrrolate 0.1 mg before the induction of anesthesia. Intraoperative monitoring was performed including pulse oximetry, electrocardiogram, capnogram, bispectral index and direct arterial pressure monitoring via radial arterial cannula. After preoxygenation, anesthesia was induced with 200 mg of thiopental and 0.5 μg/min/kg of remifentanil. After confirming the adequate mask ventilation, 40 mg of rocuronium was given to facilitate the endotracheal intubation. As expected, the endotracheal intubation was not easy. Lightwand and Airtraq Ⓡ were prepared because of the predicted difficulties in intubation. It failed using a Macintosh laryngoscope and 7.5 mm endotracheal tube using stylet and Sellick’s maneuver. We successfully intubated using Airtraq Ⓡ after we confirmed a Cormack and Lehane airway classification of Grade 3. The mechanical ventilation was started with volume controlled ventilation with a tidal volume of 550 ml and a respiratory rate of 13 /min. The anesthesia was maintained with 50% oxygen/air, 1.5–2 vol% of sevoflurane and remifentanil at 0.3 μg/min/kg. At the end of surgery, fentanyl 40 μg was used to control pain, 0.2 mg of glycopyrrolate and 1 mg of neostigmine were injected to reverse a muscle paralysis. The patient was extubated and transferred to the intensive care unit with 100% oxygen supplemented by a face mask. Trisomy 8 is a rare chromosome disorder characterized by three copies of chromosome 8 in some cells of the body. A complete trisomy 8 affects the fetal development and results in an abortion or early lethal condition. T8M is a condition that occurs when only a portion of these cells includes three copies

Endotracheal tube intubation with the aid of a laryngeal mask airway, a fiberoptic bronchoscope, and a tube exchanger in a difficult airway patient: a case report

A 28-year-old male patient with occipito-atlanto-axial instability underwent a cervical fusion with posterior technique. Post-operatively, the endotracheal tube (ETT) was removed, and the patient was transferred to the intensive care unit. After transfer, an upper airway obstruction developed and reintubations with a laryngoscope were attempted but failed. We inserted a #4 proseal laryngeal mask airway (LMA) and passed a 5.0 mm ETT through the LMA with the aid of a fiberoptic bronchoscope. We passed a tube exchanger through the 5.0 mm ETT and exchanged it with a 7.5 mm ETT. This method may be a useful alternative for difficult tracheal intubations.

Prehospital difficult airway management: old things still work

To the Editor: Airway management is a crucial skill for emergency physician, who's often called to deal with difficult airways and requests for quick, simple and effective responses, as the many factors responsible for difficulties might be enhanced by emergency setting.[1] We now have many rescue devices as the LMA, I-gel, but they do not provide a definitive airway, and recent studies evaluating the use of the videolaryngoscopes in emergency show conflicting results.[2] In contrast, endotracheal tube introducers or “Gum Elastic Bougies” (GEBs) are simple and inexpensive airway management tools that are used in cases of unanticipated difficulty. The Frova introducer (FI) (Cook® Medical, Bloomington, USA) is a commonly used example and has a high success rate for tracheal intubation in manikins.[3] We used FI in the prehospital airway management of a 40-year-old man severely burned while working in a weeds field. He sustained full-thickness (third-degree) burns over 98% of his body (Figure 1 a-​-b).b). The emergency pre-hospital rescue team of an anesthesiologist and two nurses found the patient lying on the ground. Initial vital signs were: pulse 130 per minute, respiration 36 per minute, blood pressure (S/D) 153/90 mmHg, and arterial oxygen saturation 80%. The initial Glasgow Coma Scale (GCS) was 10. The extensive burns of the face and the neck resulting in gross edema with inspiratory stridor call for immediate action to secure the airway. After initial bag-mask oxygenation, blow by oxygen (12 L per minute), the crew elected to perform a rapid sequence induction (RSI) with Frova-assisted orotracheal intubation. An intubation laryngeal mask and a surgical airway kit were at hand in case of failure. After a single intravenous bolus of ketamine (2.0 mg/kg) and succinylcholine (1 mg/kg), a direct laryngoscopy was attempted. The laryngoscopic view showed a 3 Cormack-Lehane grade: FI was then gently pushed on the midline below the visible part of the epiglottis, and the tracheal tube railroaded over it, allowing a successful intubation of the trachea, as confirmed by capnography. Continuous sedation with midazolam and fentanyl was started and the patient was referred to the Burn Centre for definitive care. Airway management in the emergency prehospital setting is often more difficult than that in the operating room. Breckwoldt et al[1] in a physician-based emergency medical system (EMS) found an incidence of difficult tracheal intubation of 13%, and an incidence of unexpected difficulty of 5%. Recently, the use of GEB in a prehospital difficult intubation algorithm has been validated,[4] however in that study the type of GEB is not specified mistakenly assuming that all GEBs are equally effective. To our knowledge, this is the first description of the use of FI in the prehospital setting. Its shape, stiffness and tip's curvature were designed to facilitate the transformation of gentle force applied to the proximal end into an anterior and upward directed movement at the distal end, resulting in a smooth shift towards a partly or completely covered laryngeal inlet (Figure 1). Also, the presence of a hollow lumen may prove useful to confirm proper tracheal placement. There may be however potential for tissue trauma, suggested by both manikin studies and case reports in the literature. Proper technique of use is critical to minimize the risk of airway trauma.[5] We think that, despite high-tech (and more expensive) gadgets growing popularity and diffusion, the “old” Frova intubating introducer, being hand-sized and easy to carry, simple to use and cheap airway device, might be a useful tool for prehospital airway management. Figure 1 A patient showing extensive burns, with a tracheal tube in situ; note tongue edema (a, b); Frova introducer: particular of the bent tip (c); simulation of CL3 grade view and Frova introducer passing on the midline below the epiglottis (d, e).

Comparing ease of intubation in obese and lean patients using intubation difficulty scale.

Background:Difficult tracheal intubation contributes to significant morbidity and mortality during induction of anesthesia. There are divided opinions regarding ease of intubation in obese patients. Moreover, the definition of difficult intubation is not uniform; hence we have use the Intubation Difficulty Scale (IDS) to find the incidence of difficult intubation in obese patients.Aims:The primary aim of the following study is to find out the incidence of difficult intubation in obese and lean patients using IDS and secondary aim is to assess the performance of bedside screening tests to predict difficult intubation, mask ventilation and laryngoscopy in obese and lean patients.Materials and Methods:A prospective, observational cohort study of 200 patients requiring general anesthesia were categorized into 100 each based on body mass index (BMI) into lean (BMI <25 kg/m2) and obese (BMI ≥25 kg/m2) groups. IDS score ≥5 was termed as difficult intubation. Pre-operative airway assessment included Mallampati score, mouth opening, neck circumference (NC), upper lip bite test, thyromental distance, sternomental distance (SMD) and head neck mobility. Patients having difficulty in mask ventilation and laryngoscopy was recorded.Results:Over all in 200 patients the incidence of difficult intubation was 9%. Obese patients were slightly more difficult to intubate than lean (11% vs. 7%, P = 0.049). Age >40 years, NC >35 cm, SMD <12.5 cm and restricted head neck mobility were factors which were associated with IDS ≥5. Multivariate analysis revealed SMD <12.5 cm to predict difficult intubation in obese patients. Obese patients were difficult to mask ventilate (6% vs. 1%, P = 0.043). There was no difference regarding grading of laryngoscopy between the two groups.Conclusion:Obese patients are difficult to mask ventilate and intubate. During intubation of obese patients who is more than 40 years age and SMD <12.5 cm, it is preferable to have a second skilled anesthesiologist.

Comparative Evaluation of Lightwand (Lighted Stylet) with Direct Laryngoscopy on Hemodynamic Response- A Prospective Study

Background:Laryngoscopy and tracheal intubation are often associated with hypertension, tachycardia, and an increase in plasma catecholamine concentrations. The present study was done to compare the hemodynamic response during tracheal intubation, guided by either Lightwand or Direct laryngoscopy. Method and patients: Seventy adult consented patients of ASA I or II aged 18-58 years of either sex scheduled for elective surgeries from September 2011 to March 2013 were randomized according to sealed envelopes into two groups of 35 patients each. The patients of Group LWI were intubated with lighted stylet (Lightwand, GE) and patients of Group DLI were intubated using direct laryngoscope (Macintosh). Any patient with history of systemic hypertension and cardiopulmonary disease, hepatic, renal or endocrine disorder, difficult airway or MP Grade III & IV, history of previous difficult tracheal intubation or patient who required more than 30 seconds or more than one attempt for intubation were excluded. The anesthetic induction technique was standardized. The hemodynamic parameters of heart rate, blood pressure and ECG were recorded, at baseline, after induction, after tracheal intubation and then at regular interval of 1 min for 5 min after tracheal intubation. Intubation time was noted by stopwatch. Results: There was no significant difference in demographic profile, in terms of changes in blood pressure and heart rate during laryngoscopy and after tracheal intubation between groups. Post intubation dysphasia, hoarseness, sore throat were also comparable between the groups. Conclusion: The effects of Lightwand technique on hemodynamic response to tracheal intubation were similar to those of direct laryngoscopy.