Difficulty In Endotracheal Intubation Research Articles

Comparative study of the difficulty of endotracheal intubation in sniffing and 25-degree backup positions

Comparative study of the difficulty of endotracheal intubation in sniffing and 25-degree backup positions

Unexpected Difficult Intubation caused by Undiagnosed Laryngeal Tuberculosis in a Patient Requiring Pericardiectomy for Tuberculosis Pericarditis: A Case Report

Airway management is a critical aspect of anesthesia, and difficulties in endotracheal intubation can lead to life threatening complications. While an anticipated difficult intubation can be managed with proper preparation and planning, unexpected difficult intubation can be a challenging situation even to skilled anesthesiologists. We experienced unexpected difficult intubation in a 66-year-old male patient with known tuberculosis pericarditis scheduled for elective pericardiectomy surgery. Multiple intubation attempts were made using various techniques, and successful intubation was achieved with a smaller diameter endotracheal tube. Surgery was uneventful and post-operative evaluation of the airway confirmed laryngeal tuberculosis. This case highlights the importance of vigilance in managing unexpected difficult intubation, especially in patients with a history of tuberculosis or immunosuppressive conditions. Prompt recognition of airway stenosis and appropriate interventions are crucial in securing the airway patency to minimize complications in patients with undiagnosed tuberculosis laryngitis.

Endotracheal intubation of small exotic mammals

The veterinary nurse or technician plays an important role in avian and exotic anaesthesia, often inducing, intubating, and maintaining an anaesthetic while the veterinary surgeon prepares for a procedure. Gone are the days of avian and exotic specialists being the only source of veterinary care for companion rodents; with an increase in the ownership of these species comes an increase in general practitioners undertaking routine or preventative health procedures. Owners of these pets expect the same standard of care afforded to dogs and cats, and consequently veterinary staff may be required to provide the same standard of intensive anaesthetic management. Successful anaesthetic management requires an awareness of patient limitations, and one such limitation in small exotic mammals is the difficulty of endotracheal intubation. Intubation allows for better respiratory control while minimising the risk of aspiration and is particularly important for procedures lasting longer than 30 minutes, during which hypoventilation and respiratory obstruction are most likely to occur. Regardless of procedure length or complexity, intubation should be the routine standard of care if it can be done in a swift and safe manner.

Airway Management: Difficulty of Intubation and Range of Movement of the Thyroid Cartilage

PurposeDifficult endotracheal intubation has been associated with a number of anatomic factors. According to our experience, the range of movement of thyroid cartilage can be used as a useful test to determine the difficulty in endotracheal intubation. The aim of this study was to evaluate the association between the range of movement of thyroid cartilage and difficulty in intubation. DesignCross-sectional study. MethodsThis study was carried out on 400 patients at (Shohada Ashayer Hospital, Khorramabad). After obtaining consent letters from the patients who were between 18 and 60 years of age, the patients underwent general anesthesia. The participants were evaluated by Mallampati and other evaluating tests. The range of movement of thyroid cartilage from the midline was measured and recorded. FindingsThere were significant correlation between the range of movement of thyroid cartilage and thyromental distance. In addition, in patients with Cormack-Lehane class 1, the mean range of movement of thyroid cartilage was significantly more than the patients with Cormack-Lehane class 3 and 4. ConclusionsThe outcomes of our study indicate that the range of movement of thyroid cartilage can be used for predication of difficult intubation. However, further randomized trials should be conducted in this regard.

Comparative Study of Upper Lip Bite Test and Modified Mallampatti Classification in Predicting Difficult Endotracheal Intubation

Objective: To compare sensitivity, specificity, positive and negative predictive values of upper lip bite test and modified mallampatti test to predict difficulty in endotracheal intubation in patients between 16 to 55 years of age. Methods: One hundred ASA1/2 patients admitted for elective surgical procedure requiring endotracheal intubation were prospectively studied to predict difficult intubation in age group 16-55 years of age after obtaining an informed consent. Preoperative Airway assessment was done with modified mallampatti test and upper lip bite test. Results: In our study, eighty four had Upper lip bite test (ULBT) class I and II and sixteen patients had class III. Of these two ofthe ULBT class Iand II and five of the ULBTclassIII had Cormack Lehane grade III . There were one hundred patients predicted to be easy for intubation by MMT (i.e. patients who had ULBT class I and II) out of whom however, we encountered difficult intubation in 6 patients. One in MMT class III also had difficult intubation. None of the patients had class IV MMT.Of the entire one hundred patients, a total of seven patients had difficult intubation, all of whom had Cormack Lehane class III on laryngoscopy. Conclusion: Upper Lip Bite Test (ULBT)is a better test at predicting difficult endotracheal intubation when compared toModified Mallampati Test (MMT). Upper lip bite test and modified mallampatti classification are good predictors of easy intubation rather than difficult intubation. Upper lip bite test should be used in combination with other airway assessment methods viz. Thyromental distance, hyomental distance, inter incisor distance to predict difficult intubation.

Comparison of McGrath Videolaryngoscope and Macintosh Laryngoscope in Children with Torticollis: Randomized Controlled Trial.

We investigated the efficacy of the McGrath videolaryngoscope compared with the Macintosh laryngoscope in children with torticollis. Thirty children aged 1–10 years who underwent surgical release of torticollis were randomly assigned into the McGrath and Macintosh groups. Orotracheal intubation was performed by a skilled anesthesiologist. The primary outcome was the intubation time. The Cormack–Lehane grade, lifting force, intubation difficulty scale (IDS), difficulty level, and intubation failure rate were also assessed. The intubation time was significantly longer in the McGrath group than in the Macintosh group (31.4 ± 6.7 s vs. 26.1 ± 5.4 s, p = 0.025). Additionally, the Cormack–Lehane grades were comparable between the groups (p = 0.101). The lifting force and IDS were significantly lower in the McGrath group than in the Macintosh group (p < 0.001 and p = 0.022, respectively). No significant differences were observed with respect to endotracheal intubation difficulty and intubation success rate. Intubation-related complications were also not observed. In conclusion, compared with the Macintosh laryngoscope, the McGrath videolaryngoscope extended the intubation time and did not improve glottic visualization in children with torticollis, despite having a lesser lifting force, lower intubation difficulty scale, and similar success rate.

Impact of aerosol box on anxiety of the anaesthesiologist for intubation during COVID-19 pandemic: A single-blinded observational study.

Sir, Reports of healthcare workers (HCWs) getting infected during the coronavirus disease-19 pandemic are disturbing and tragic. The risk posed to HCWs especially anaesthesiologists during aerosol generating procedures (AGPs) is critical. Innovation of the aerosol box (AB) (made of acrylic or transparent polycarbonate sheet) may help to address this issue.[1] AB is a transparent plastic cube designed to cover a patient's head and has two circular ports through which the clinician's hands are passed to perform the airway procedure. It is a barrier device useful as an anti-splash or against direct cough from patient into the face of the proceduralist.[2] We conducted a survey from July 2020 to December 2020 to evaluate whether the AB really played a vital role in allaying anxiety of the anaesthesiologist regarding the risk of direct aerosol exposure or was it a hurdle in smooth working. The survey was distributed to experienced anaesthesiologists, who were routinely doing cases in general anaesthesia. After prior consent, we distributed the online survey to anaesthesiologists through their institutional emails, social media and WhatsApp messenger in our city. No data which could breech personal information was collected. They filled the questionnaire which enquired about their awareness, experiences, adventures and misadventures during induction and extubation with the AB [Table 1].Table 1: The questionnaireNinety anaesthesiologists responded to the survey questions. Only 29.60% of the participants had prior experience with the AB [Table 2]. Almost 70.40% of the study population was unaware of the use of this innovative barrier device. 46.30% participants came to know about AB from colleagues, whereas the rest came to know from social media and other sources. Thus, the results depicted that no first-hand experience or hands-on training for anaesthesiologists was present prior to using this box. 11.10% of the participants had an overall nice experience with use of AB while performing intubation and 85.20% felt that though it was helpful, it was a hurdle for intubation. 3.70% of the participants found it to be hazardous. Bag and mask ventilation was found to be easy by 14.80%, while 57.40% found bag and mask ventilation difficult with use of the box [Table 2]. Ease with endotracheal intubation was reported by 9.30%, while 83.30% of the participants faced difficulty. The majority (70.40%) of the participants agreed that AB prevented contamination with aerosol particles, whereas 13% disagreed about the efficacy. Use of AB made 68.50% of the participants mentally composed, while the rest were anxious. 7.40% of the participants felt that nothing can affect the composure of an anaesthesiologist. 55.60% of the respondents were more comfortable working with level 3 personal protective equipment (PPE) without AB. Almost 72.2% of the participants agreed to recommend AB to other colleagues for AGPs. During extubation, 37.0% of the participants were under-confident in use of the box, while 18.5% of the participants felt that it did not affect their psychology during extubation.Table 2: Summary of responses to all questionsOverall experience of the anaesthesiologists as per our survey was that the box acts as a hurdle for intubation and made bag and mask ventilation and intubation difficult. However, 70% of the study population felt that it prevented contamination with aerosol during AGPs, which was in compliance with the study conducted by Dalli et al.[3] This was in contrast to the study by Wakabayashi et al.,[4] who concluded that the effect of AB on endotracheal intubation difficulty is clinically irrelevant when an experienced anaesthesiologist intubates the trachea in normal airway conditions. The survey was inconclusive with regards to the confidence of the anaesthesiologist during extubation as per the meta-analysis by Sorbello et al.[5] The survey could also not conclude on the comfort with the use of the box as compared to level 3 PPE and was lacking in views on chances of accidental extubation and the box acting as an oxygen and virus reservoir.[6] We concluded from the survey that though the AB allays the anxiety of the anaesthesiologist, it acts as a hurdle for intubation during AGPs. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgment The authors thank Dr Saifullah Tipu for his help in conducting the study.

Anterior Cervical Idiopathic Hyperostosis and Dysphagia: The Impact of Surgical Management—Study of a Series of 11 Cases

To assess the efficacy and safety of surgery for dysphagia in anterior cervical idiopathic hyperostosis. This retrospective study included 11 consecutive patients presenting with dysphagia and anterior cervical idiopathic hyperostosis. Computed tomography scans and dynamic swallowing fluoroscopies were performed. The site of compression and the size and position of osteophytes were measured. The clinical outcomes and complications were recorded. Two patients with anterior esophageal compression were found to have dysphagia caused by lower esophageal sphincter dysfunction. In the remaining 9patients, the level of maximal compression was between C3 and C5 with the size of the osteophytes ranging from 8 to 17 mm. Intubation was challenging in 7 patients. Postoperative transient worsening of dysphagia was encountered in 3 patients. Two patients experienced severe complications including aphagia and respiratory compromise. Within 2 months of the operation, all patients reported satisfactory improvement of symptoms and a considerable gain in quality of life. No recurrence had occurred at final follow-up. Anterior cervical hyperostosis causing dysphagia typically affects older men and results from compression between C3 and C5 from osteophytes of variable sizes. Operative intervention can provide long-lasting resolution of symptoms but is complicated by difficulty in endotracheal intubation, postoperative dysphagia, and rarely respiratory compromise. A systematic preoperative ear, nose, and throat consultation is recommended to reduce these complications.

How to Predict Difficult Tracheal Intubation: The Application of Acromio-axillo-suprasternal Notch Index.

Background:The incidence of difficult laryngoscopy or tracheal intubation is high, which needs a method to predict the difficulty of tracheal intubation to decrease the rate of complications. Therefore, the aim of this study was to evaluate acromio-axillo-suprasternal notch index (AASI) method for predicting difficult tracheal intubation and difficult laryngoscopy.Materials and Methods:This cross-sectional and diagnostic value study was performed on 108 patients who had indication for endotracheal intubation in the emergency department. Before endotracheal intubation, AASI was evaluated in all patients. The sensitivity, specificity, and total accuracy for predicting the power of AASI for the difficulty of tracheal intubation were measured.Results:Based on Cormack and Lehane grading system, 54 patients had easy endotracheal intubation (33.3% Grade I and 66.6% Grade II) and 52 patients had difficult endotracheal intubation (57.7% Grade III and 32.7% Grade IV). The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy for AASI in cutoff point 0.515 for predicting difficulty of endotracheal intubation with 0.857 area under the receiver operating characteristic curve were 84.6%, 77.7%, 78.5%, 84%, and 81.13%, respectively.Conclusions:Our results showed that predicting difficulty of endotracheal intubation by AASI is accurate and with high sensitivity and specificity values, therefore, training this method to emergency physicians should be considered in our country or other countries. Further studies are required to confirm our findings.

Generative Anatomy Modeling Language (GAML)

This paper presents the Generative Anatomy Modeling Language (GAML) for generating variation of 3D virtual human anatomy in real-time. This framework provides a set of operators for modification of a reference base 3D anatomy. The perturbation of the 3D models is satisfied with nonlinear geometry constraints to create an authentic human anatomy. GAML was used to create 3D difficult anatomical scenarios for virtual simulation of airway management techniques such as Endotracheal Intubation (ETI) and Cricothyroidotomy (CCT). Difficult scenarios for each technique were defined and the model variations procedurally created with GAML. This study presents details of the GAML design, set of operators, types of constraints. Cases of CCT and ETI difficulty were generated and confirmed by expert surgeons. Execution performance pertaining to an increasing complexity of constraints using nonlinear programming was in real-time execution.

Comparison of upper lip bite test with modified Mallampatti classification for predicting difficulty in endotracheal intubation: A prospective study

Comparison of upper lip bite test with modified Mallampatti classification for predicting difficulty in endotracheal intubation: A prospective study

The Performance of the Intubation Difficulty Scale among Obese Parturients Undergoing Cesarean Section.

Background. There have not yet been any studies to validate the intubation difficulty scale (IDS) in obese parturients. Objectives of this study were to determine the performance of the IDS in defining difficult intubation (DI) and to identify the optimal cutoff points of the IDS among obese parturients. Methods. This was a prospective observational study. Parturients with a body mass index ≥ 30 kg/m2 who underwent cesarean section utilizing endotracheal intubation were enrolled. The intubating performers were asked to assess the difficulty of endotracheal intubation and categorize it as easy, somewhat DI, and DI. Main Results. A total of 517 parturients were recruited with a mean BMI of 33.9 kg/m2. The incidence of some degree of DI was 14.5%. The area under the receiver operating characteristic curves of the IDS for detecting somewhat DI and DI was 1.0. The optimal cutoff point to define somewhat DI was ≥3 and DI was ≥5, which both had sensitivity and specificity of 100%. Conclusions. The IDS scoring is a good tool for defining DI among obese parturients. The IDS scores of ≥3 and ≥5 are the optimal cutoff points to define somewhat DI and DI, respectively.

Supraglottic Kaposi’s Sarcoma in HIV-Negative Patients: Case Report and Literature Review

This paper presents a case report of an HIV-negative, supraglottic Kaposi's sarcoma patient. The 80-year-old male patient was admitted with complaints of hoarseness, difficulty in swallowing, and a stinging sensation in his throat for approximately six months. The endoscopic larynx examination revealed a lesion which had completely infiltrated the epiglottis, reached right aryepiglottic fold, was vegetating, pink and purple in color, multilobular, fragile, and shaped like a bunch of grapes, and partially blocked the bleeding airway passage. The case was discussed by the hospital's head-neck cancer committee and a surgery decision was made. A tracheotomy was performed under local anesthesia before the operation due to respiratory distress and endotracheal intubation difficulty. Direct laryngoscopy showed that the mass was limited in the supraglottic area, had invaded the entire left aryepiglottic fold and one-third of the front right aryepiglottic fold, and completely covered epiglottis. It should be remembered that although rare, Kaposi's sarcoma may be encountered in larynx malignancy cases. Disease-free survival may be achieved through local excision and postoperative radiotherapy.

Effects of airway evaluation parameters on the laryngeal view grade in mandibular prognathism and retrognathism patients.

BackgroundFailure to maintain a patent airway can result in brain damage or death. In patients with mandibular prognathism or retrognathism, intubation is generally thought to be difficult. We determined the degree of difficulty of airway management in patients with mandibular deformity using anatomic criteria to define and grade difficulty of endotracheal intubation with direct laryngoscopy.MethodsMeasurements were performed on 133 patients with prognathism and 33 with retrognathism scheduled for corrective esthetic surgery. A case study was performed on 89 patients with a normal mandible as the control group. In all patients, mouth opening distance (MOD), mandibular depth (MD), mandibular length (ML), mouth opening angle (MOA), neck extension angle (EXT), neck flexion angle (FLX), thyromental distance (TMD), inter-notch distance (IND), thyromental area (TMA), Mallampati grade, and Cormack and Lehane grade were measured.ResultsCormack and Lehane grade I was observed in 84.2%, grade II in 15.0%, and grade III in 0.8% of mandibular prognathism cases; among retrognathism cases, 45.4% were grade I, 27.3% grade II, and 27.3% grade III; among controls, 65.2% were grade I, 26.9% were grade II, and 7.9% were grade III. MOD, MOA, ML, TMD, and TMA were greater in the prognathism group than in the control and retrognathism groups (P < 0.05). The measurements of ML were shorter in retrognathism than in the control and prognathism groups (P < 0.05).ConclusionsLaryngoscopic intubation was easier in patients with prognathism than in those with normal mandibles. However, in retrognathism, the laryngeal view grade was poor and the ML was an important factor.

Dental trauma prevention during endotracheal intubation--review of literature.

Endotracheal intubation is a procedure performed during general anaesthesia with the use of an endotracheal tube in order to maintain a patent airway. This routinely used procedure is connected with a risk of complications within the region of the masticatory system. Trauma of teeth, their surrounding structures and the soft tissue of the oral cavity is observed in app. 1.38 per 1000 procedures. The main causes of this damage are the surgical skills and experience of the surgeon, the anatomical conditions present and the mode of conducting the procedure. In order to reduce the risk of postoperative complications, patients with a high risk of sustaining an injury during endotracheal intubation should be equipped with elastic mouthguards, which reduces the possibility of damage. The scoring in a scale of endotracheal intubation difficulty should be used for qualification for the use of such mouthguards.

Airway challenges in thyroid surgery

Huge goiters can lead to tracheal compression and, hence, difficulty in endotracheal intubation. This along with retro-sternal extension makes it an anticipated difficult airway scenario. In this report, we present a case of huge goiter (papillary carcinoma) compromising the airway, which presented with difficult airway for total thyroidectomy. CT scan of neck revealed retro-sternal extension with the pretracheal plane fixed to the trachea. Trachea was completely pushed to the right. We successfully performed an awake direct laryngoscopy and successful intubation by locally anesthetizing the airway. Plan B was ready with fiberoptic bronchoscopy and rigid bronchoscopy. Patient was successfully extubated in the intensive care unit (ICU).

Anesthetic Management of a Child with Simpson-Golabi-Behmel Syndrome—A Case Report

Simpson-Golabi-Behmel syndrome (SGBS) is an X-linked recessive condition associated with pre-natal and postnatal overgrowth with visceral and skeletal anomalies. Abnormal airway anatomy may complicate the perioperative management of SGBS. However, there have been few reports regarding the anesthetic management of children with SGBS. We present the preoperative evalua-tion and intraoperative management of a 1.5-year-old child with SGBS undergoing plastic surgery for cleft palate. Sevoflurane-fentanyl anesthesia without a neuromuscular blocker was planned, due to the preoperative evaluation that airway management would be complicated by the macroglossia and short neck characteristic of SGBS. Fortunately, there was no difficulty in endotracheal intubation in the present patient due to careful planning of general anesthesia and meticulous airway management. Appropriate preoperative preparation for a difficult airway by the anesthe-siologist can ameliorate the difficulties inherent to the anesthetic management of patients with SGBS.

Correlación entre los formatos de la orofaringe e hipofaringe y el posicionamiento en la intubación endotraqueal difícil

Background and objectivePrediction of intubation difficulty can save patients from major preoperative morbidity or mortality. The purpose of this paper is to assess the correlation between oro-hypo pharynx position, neck size, and length with endotracheal intubation difficulty. The study also explored the diagnostic value of Friedman Staging System in prediction cases with difficult intubation. MethodThe consecutive 500 ASA (I, II) adult patients undergoing elective surgery were evaluated for oro and hypopharynx shape and position by modified Mallampati, Cormack and Lehane score as well as Friedman obstructive sleep apnea classification systems. Neck circumference and length were also measured. All cases were intubated by a single anesthesiologist who was uninformed of the above evaluation and graded intubation difficulty in visual analog score. Correlation between these findings and difficulty of intubation was assessed. Sensitivity, specificity, positive and negative predictive values were also reported. ResultsCormack-Lehane grade had the strongest correlation with difficulty of intubation followed by Friedman palate position. Friedman palate position was the most sensitive and had higher positive and negative predictive values than modified Mallampati classification. Cormack-Lehane grade was found to be the most specific with the highest negative predictive value among the four studied classifications. ConclusionFriedman palate position is a more useful, valuable and sensitive test compared to the modified Mallampati screening test for pre-anesthetic prediction of difficult intubation where its involvement in multivariate model may raise the accuracy and diagnostic value of preoperative assessment of difficult airway.

Correlação entre os formatos da orofaringe e hipofaringe e posicionamento em intubação endotraqueal difícil

Background and objectivePrediction of intubation difficulty can save patients from major preoperative morbidity or mortality. The purpose of this paper is to assess the correlation between oro–hypo pharynx position, neck size, and length with endotracheal intubation difficulty. The study also explored the diagnostic value of Friedman Staging System in prediction cases with difficult intubation. MethodThe consecutive 500 ASA (I, II) adult patients undergoing elective surgery were evaluated for oro and hypopharynx shape and position by modified Mallampati, Cormack and Lehane score as well as Friedman obstructive sleep apnea classification systems. Neck circumference and length were also measured. All cases were intubated by a single anesthesiologist who was uninformed of the above evaluation and graded intubation difficulty in visual analog score. Correlation between these findings and difficulty of intubation was assessed. Sensitivity, Specificity, Positive and Negative Predictive Values were also reported. ResultsCormack–Lehane grade had the strongest correlation with difficulty of intubation followed by Friedman palate position. Friedman palate position was the most sensitive and had higher positive and negative predictive values than modified Mallampati classification. Cormack–Lehane grade was found to be the most specific with the highest negative predictive value among the four studied classifications. ConclusionFriedman palate position is a more useful, valuable and sensitive test compared to the modified Mallampati screening test for pre‐anesthetic prediction of difficult intubation where its involvement in Multivariate model may raise the accuracy and diagnostic value of preoperative assessment of difficult airway.

Correlation between oro and hypopharynx shape and position with endotracheal intubation difficulty

Background and objectivePrediction of intubation difficulty can save patients from major preoperative morbidity or mortality. The purpose of this paper is to assess the correlation between oro–hypo pharynx position, neck size, and length with endotracheal intubation difficulty. The study also explored the diagnostic value of Friedman Staging System in prediction cases with difficult intubation. MethodThe consecutive 500 ASA (I, II) adult patients undergoing elective surgery were evaluated for oro and hypopharynx shape and position by modified Mallampati, Cormack and Lehane score as well as Friedman obstructive sleep apnea classification systems. Neck circumference and length were also measured. All cases were intubated by a single anesthesiologist who was uninformed of the above evaluation and graded intubation difficulty in visual analog score. Correlation between these findings and difficulty of intubation was assessed. Sensitivity, Specificity, Positive and Negative Predictive Values were also reported. ResultsCormack–Lehane grade had the strongest correlation with difficulty of intubation followed by Friedman palate position. Friedman palate position was the most sensitive and had higher positive and negative predictive values than modified Mallampati classification. Cormack–Lehane grade was found to be the most specific with the highest negative predictive value among the four studied classifications. ConclusionFriedman palate position is a more useful, valuable and sensitive test compared to the modified Mallampati screening test for pre-anesthetic prediction of difficult intubation where its involvement in Multivariate model may raise the accuracy and diagnostic value of preoperative assessment of difficult airway.