First-attempt Intubation Success Research Articles

Comparison of BlockBuster laryngeal mask with Air-Q intubating laryngeal airway as a conduit for fiber-optic guided intubation in children: A prospective randomized controlled study.

The pediatric sizes of BlockBuster supraglottic airway (SGA) have been introduced recently. Its efficacy as a conduit for endotracheal intubation in children has not been assessed. Newer devices are often compared with Air-Q SGA to assess their intubating capability. The primary objective was to compare the time taken for fiber-optic-guided intubation through the BlockBuster and the Air-Q SGAs. Sixty children aged 6 months to 12 years with normal airways were randomized into two groups: Air-Q SGA (Group A) and Blockbuster SGA (Group B). After administration of general anesthesia, an appropriately sized SGA was inserted. The time taken for fiber-optic-guided intubation through the SGA, success, ease, and time for SGA insertion and removal were noted. The glottic view was graded by fiber-optic bronchoscopy. Demographic parameters were comparable. The time to intubate with the BlockBuster 62.40 ± 17.2 s was comparable to the Air-Q 60.8 ± 18.5 s (mean difference 1.6 s, 95% CI -7.65 to10.85; p = .73). The average time for SGA insertion in BlockBuster and Air-Q was 14.57 ± 3.2 s and 16.67 ± 5.39 s, respectively (mean difference -2.1, 95% CI -4.39 to 0.19 s; p = .07). The first-attempt intubation success and overall intubation success rates were comparable in both groups, 96.7% and 100%, respectively. In Group B, 25/3/1/1/0 cases had a glottic view grade of 1/2/3/4/5, respectively. In Group A, 23/3/2/2/0 cases had grade of 1/2/3/4/5 glottic views respectively. The average time to SGA removal was comparable between the BlockBuster (20.17 ± 5.8 s) and the Air-Q (22.5 ± 12.8 s) groups (mean difference -2.3 s, 95% CI -7.5 to 2.82 s; p = .37). None of the children had any perioperative complications. BlockBuster SGA may be a useful alternative to Air-Q for SGA-assisted, fiber-optic-guided tracheal intubation in children.

Systematic Review and Meta-Analysis of Randomized Controlled Trials (RCTs) Revealing the Future of Airway Management: Video Laryngoscopy vs. Macintosh Laryngoscopy for Enhanced Clinical Outcomes.

Since the 1940s, Macintosh laryngoscopy (Mac laryngoscopy) has been the gold standard for tracheal intubation, offering visualization of the glottis entrance. However, recent years have witnessed the emergence of various video laryngoscopy (VL) techniques. This systematic review and meta-analysis aims to assess the clinical outcomes of VL versus Mac laryngoscopy in an elective setting. We comprehensively searched five medical databases - PubMed, EMBASE, Medline, Cochrane Library, and Web of Science. All the databases were last searched in January 2023. We only included studies with full texts comparing VL to Mac laryngoscopy clinical outcomes. Studies were excluded if they were non-full text or non-randomized controlled trials (RCTs) and did not compare VL to Mac laryngoscopy. We extracted data comprising author names, publication year, key study outcomes (first-attempt intubation success rate, Cormack and Lehane grade, hypoxia incidence, and glottis view quality), video laryngoscope types, and sample sizes of both VL and Mac laryngoscopy groups. The Cochrane risk of bias tool was used to assess the risk of bias in the included studies. Statistical analysis was performed using Review Manager (RevMan, version 5.4;Cochrane Collaboration, London, UK), presenting results as odds ratio (OR) and risk ratios (RR) at a 95% confidence interval (CI). This facilitated the identification of relevant and appropriate studies of our analysis. The search produced 19 studies that were included in this review. The evaluated sample size ranges from 40 to 802, with 3,238 participants. The rate of success at the first attempt in the use of VL was 1,558/1,890 (82.43%), while the success rate for Mac laryngoscopy was 982/1,348 (72.85%; OR: 1.98 (1.25, 3.12)) at a 95% confidence interval. Pooled analysis indicated no significant difference for hypoxia concerning the type of device used RR (random effects: 1.02; 95% CI: 0.80-1.29). A video laryngoscope had a higher likelihood of visualizing the vocal cords categorized as category 1 in the Cormack-Lehane system of classification (RR: 2.45; 95% CI: 1.43-4.21). Additionally, considerably better glottis views were attained during VL than Mac laryngoscopy (OR: 1.77; 95% CI: 1.19-2.62). In elective tracheal intubation, VL demonstrates superior first-attempt success rates, offers improved glottis visualization, and reduces instances where the glottis cannot be viewed compared to Mac laryngoscopy.

First-Pass Success of Video Laryngoscope Compared With Direct Laryngoscope in Intubations Performed by Residents in the Emergency Department.

The video laryngoscope (VL) has been widely used for intubation in the emergency department (ED). However, their effectiveness remains controversial, particularly among airway management performed by residents in the ED. We aimed to examine whether the use of VL, compared to a direct laryngoscope (DL), was associated with higher first-attempt intubation success among intubations performed by residents in the ED. This is a secondary analysis of the data from a prospective, observational, multicentre study of 15 Japanese EDs from April 2012 through March 2020. We included all adult patients who underwent intubation with VL or DL by residents (postgraduate years ≤5) in the ED. The outcome measures were first-pass success and intubation-related adverse events (overall, major, and minor adverse events). To determine the association of VL use with each of the outcomes, we constructed logistic regression models with generalized estimating equations to account for patients clustering within the ED, adjusting for patient demographics, primary indications, intubation difficulty, and intubation methods. Of 5,261 eligible patients who underwent an initial intubation attempt by residents, 1,858 (35%) patients were attempted with VL. Intubations performed with VL had a non-significantly higher first-pass success rate than those with DL (77% vs. 64%; unadjusted odds ratio (OR)=1.20; 95% CI=0.87-1.65; P=0.27). This association was significant after adjustment for potential confounders (adjusted OR, 1.33; 95% CI, 1.06-1.67; P=0.01). As for adverse events, the use of VL was associated with a lower rate of any (adjusted OR=0.67; 95% CI=0.51-0.86; P=0.002) and minor (adjusted OR=0.69; 95% CI=0.55-0.87; P=0.002) adverse events. The use of VL was associated with a higher first-attempt success rate and a lower rate of any adverse events compared to that with DL among intubations performed by residents in the EDs.

Effect of Bougie Use on First-Attempt Success in Tracheal Intubations: A Systematic Review and Meta-Analysis

The use of a bougie, a flexible endotracheal tube introducer, has been proposed to optimize first-attempt success in emergency department intubations. We aimed to evaluate the available evidence on the association of bougie use in the first attempt and success in tracheal intubations. This was a systematic review and meta-analysis of studies that evaluated first-attempt success between adults intubated with a bougie versus without a bougie (usually with a stylet) in all settings. Manikin and cadaver studies were excluded. A medical librarian searched Ovid Cochrane Central, Ovid Embase, Ovid Medline, Scopus, and Web of Science for randomized controlled trials and comparative observational studies from inception to June 2023. Study selection and data extraction were done in duplicate by 2 independent reviewers. We conducted a meta-analysis with random-effects models, and we used GRADE to assess the certainty of evidence at the outcome level. We screened a total of 2,699 studies, and 133 were selected for full-text review. A total of 18 studies, including 12 randomized controlled trials, underwent quantitative analysis. In the meta-analysis of 18 studies (9,151 patients), bougie use was associated with increased first-attempt intubation success (pooled risk ratio [RR] 1.11, 95% confidence interval [CI] 1.06 to 1.17, low certainty evidence). Bougie use was associated with increased first-attempt success across all analyzed subgroups with similar effect estimates, including in emergency intubations (9 studies; 8,070 patients; RR 1.11, 95% CI 1.05 to 1.16, low certainty). The highest point estimate favoring the use of a bougie was in the subgroup of patients with Cormack-Lehane III or IV (5 studies, 585 patients, RR 1.60, 95% CI 1.40 to 1.84, moderate certainty). In this meta-analysis, the bougie as an aid in the first intubation attempt was associated with increased success. Despite the certainty of evidence being low, these data suggest that a bougie should probably be used first and not as a rescue device in emergency intubations.

Comparison of Tracheal Intubation Using King Vision (Non-channeled Blade) and Tuoren Video Laryngoscopes in Patients With Cervical Spine Immobilization by Manual In-Line Stabilization: A Randomized Clinical Trial.

Glottic visualization on cervical immobilization with manual in-line stabilization (MILS) might be challenging in individuals with cervical spine injuries. We compared non-channeled King Vision video laryngoscope (VL) (Ambu GmbH, Bad Nauheim, Germany) with Tuoren video laryngoscope (Henan Tuoren Medical Device, Zhengzhou, China) for endotracheal intubation in patients with cervical spine immobilization. A total of 124 patients undergoing elective surgery under general anesthesia were included in this study. After induction of general anesthesia, patients were randomized into two groups (62 each): group K (non-channeled blade of King Vision video laryngoscope) and group T (Tuoren video laryngoscope). Cervical spine immobilization was achieved with manual in-line stabilization. The success of the first pass intubation, the time required to intubate, glottic visualization, and intubation difficulty score (IDS) were recorded. The first-attempt success rate of intubation was 95.2% (59 out of 62 patients) in group K and 90.3% (56 out of 62 patients) in group T, which were comparable. The mean glottic visualization time was significantly less with group T (12.74 ± 6.32 seconds) compared to group K (17.92 ± 4.24 seconds). Intubation time was significantly faster with group K (18.79 ± 5.857 seconds) compared to group T (27.21 ± 8.514 seconds). Both video laryngoscopes provided good grades of glottic visualization. We conclude that the performance of the Tuoren video laryngoscope is similar to the King Vision video laryngoscope in terms of first-attempt intubation success rate and glottic visualization score in patients with cervical spine immobilization by manual in-line stabilization. Although glottic visualization time was shorter with Tuoren VL, we could achieve faster intubationwith King Vision VL.

Learning curve for flexible bronchoscope-guided orotracheal intubation for anesthesiology residents: A cumulative sum analysis.

Endotracheal intubation with a flexible bronchoscope is a well-recognized airway management technique that anesthesiologists must master. Skill acquisition and knowledge must reach an appropriate level before trainees perform independent practice on patients. There are a paucity of evidence-based outcome measures of trainee competence in performing flexible bronchoscopy. The objectives of this study were to 1) construct a learning curve for flexible bronchoscope-guided orotracheal intubation for anesthesiology residents using the CUSUM method and 2) determine the number of procedures required to achieve proficiency. This study included 12 first-year anesthesiology residents with no previous experience with flexible bronchoscopic intubation. Trainees attended theoretical and simulation training and performed flexible bronchoscope-guided orotracheal intubation in adult patients with normal airways under general anesthesia. Number of intubation attempts, intubation success rate, time to intubation, and incidence of dental and mucosal injuries were recorded. The cumulative sum (CUSUM) method was used to evaluate the learning curve of flexible bronchoscope-guided orotracheal intubation. Trainees performed flexible bronchoscope-guided orotracheal intubation on 364 patients. First-attempt intubation success occurred in 317 (87.1%) patients. Second-attempt intubation success occurred in 23 (6.3%) patients. Overall, the flexible bronchoscope-guided orotracheal intubation success rate was 93.4% (range, 85.3% to 100%). The mean number of orotracheal intubation procedures per trainee was 31 ± 5 (range, 23 to 40). All trainees crossed the lower decision boundary (H0) after 15.1 ± 5.6 procedures (range, 8 to 25 procedures). There was a significant decrease in median intubation time [39s (IQR: 30, 50) vs. 76s (IQR: 54, 119)] (P < 0.001) after crossing the lower decision boundary (H0) compared to before. There were no dental, mucosa, arytenoid or vocal cord trauma events associated with intubation. Learning curves constructed with CUSUM analysis showed that all trainees (anesthesiologist residents) included in this study achieved competence (intubation success rates ≥ 80%) in flexible bronchoscope-guided orotracheal intubation. Trainees needed to perform 15 (range, 8 to 25) procedures to achieve proficiency. There was wide variability between trainees. Trial registration: Chinese Clinical Trial Register, ChiCTR 2000032166.

The Pediatric Bougie for the First Tracheal Intubation Attempt in Critically Ill Children.

Bougie use during emergency tracheal intubation has not been well studied in children. This was a 10-year observational study of pediatric intubations (<18 years of age) in the emergency department (ED) of an academic institution. Bougie training and use are standard in our ED, including for emergency medicine residents. Study data were collected by a combination of charts and video reviews. We compare first-attempt intubation success and procedural complications between pediatric patients with and without bougie use during tracheal intubation in the ED. In addition, we evaluate the independent association of bougie use with first-attempt intubation success using multivariable logistic regression. We collected data on intubation success and bougie use for 195 pediatric patients over more than 10 years. On the first tracheal intubation attempt, a pediatric bougie was used in 126 patients (65%). Median patient age was 5 years (interquartile range 1.7 to 9) in the bougie group and 1.7 years (interquartile range 0.2 to 5) in the no bougie group. Intubation was successful on the first attempt in 72% of intubations with a bougie versus 78% without a bougie (absolute difference -6%, 95% confidence interval [CI] -19 to 6%); the adjusted odds of first-attempt success with a bougie were 0.54 (95% CI 0.24 to 1.19). A procedural complication occurred for 38% of patients in the bougie group versus 51% in the no bougie group (-13%, 95% CI -27% to 2%). Two neonates, one in each group, experienced a potential injury to the airway or lower respiratory tract. In an academic ED where the bougie is commonly used, bougie use in children was not associated with procedural success or complications. Our study suggests that a randomized clinical trial is needed to determine the effect of bougie use during emergency pediatric intubation.

First-Attempt Intubation Success Among Emergency Medicine Trainees by Laryngoscopic Device and Training Year: A National Emergency Airway Registry Study.

We compare intubation first-attempt success with the direct laryngoscope, hyperangulated video laryngoscope, and standard geometry video laryngoscope among emergency medicine residents at various postgraduate years (PGY) of training. We analyzed prospective data from emergency department (ED) patients enrolled in the National Emergency Airway Registry from January 1, 2016 to December 31, 2018 using mixed-effects logistic regression to assess the association between PGY of training and first-attempt success by the device. Among 15,204 intubations performed by emergency medicine trainees, first-attempt success for PGY-1, PGY-2, and PGY3+ residents, respectively were: 78.8% (95% CI, 75.0 to 82.2%), 81.3% (79.4 to 83.0), and 83.6% (95% CI, 82.1 to 85.1) for direct laryngoscope; 87.2% (95% CI, 84.2 to 89.7), 90.4% (95% CI, 88.8 to 91.9%), and 91.2% (95% CI, 89.8 to 92.5%) for hyperangulated video laryngoscope; and 88.7% (95% CI, 86.1 to 90.9), 90.2% (95% CI, 88.7 to 91.5%), and 94.6% (95% CI 93.9 to 95.3%) for standard geometry video laryngoscope. Direct laryngoscope first-attempt success improved for PGY-2 (adjusted odds ratio [aOR],1.41; 95% CI, 1.09 to 1.82) and PGY-3+ (aOR, 1.76; 1.36 to 2.27) trainees compared to PGY-1. Hyperangulated video laryngoscope success also improved for PGY-2 (aOR, 1.51; 1.1 to 2.05) and PGY-3+ (aOR, 1.56; 1.15 to 2.13) trainees compared to PGY-1. For the standard geometry video laryngoscope, only PGY-3+ (aOR, 1.72; 1.25 to 2.36) was associated with improved first-attempt success compared to PGY-1. Each laryngoscopy device class was associated with improvement in first-attempt success as training progressed. The video laryngoscope outperformed the direct laryngoscope for all operator groups, and PGY-1 trainees achieved higher first-attempt success using a standard geometry video laryngoscope than PGY-3+ trainees using a direct laryngoscope. These findings support the conjecture that in adult patients, a direct laryngoscope should not be routinely used for the first intubation attempt unless clinical circumstances, such as the presence of a soiled airway, would favor its success. These findings need to be validated with prospective randomized clinical trials.

Essentials of Airway Management: The Best Tools and Positioning for First-Attempt Intubation Success

Head position during endotracheal intubation affects first-attempt success, as does the different tools available and the location. It is important to be skilled in the operation of a variety of laryngoscopes (video or direct) as well as introducers (plastic/steel stylets and bougies). Difficult airways should always be anticipated and proper preparation such as upper airway assessment performed. The following is a review of endotracheal intubations performed outside of the operating room.

Videolaryngoscopy as a primary intubation modality in obstetrics: A narrative review of current evidence.

Pregnancy-related physiologic and anatomic changes affect oxygenation and airway management, and it is widely believed that airway difficulty may be more common in obstetric patients as a result. In addition, most obstetric intubations are performed under emergency conditions, and preoperative airway assessment poorly predicts airway management outcomes. These considerations necessitate special protocols for airway care in the obstetric population, and the evolution of the videolaryngoscope represents one of the most important milestones in recent decades. However, recommendations for the use of videolaryngoscopy in obstetrics remain unclear. A considerable body of evidence affirms that videolaryngoscopy improves laryngeal visualisation, increases first-attempt and overall intubation success rates, shortens intubation time, and facilitates team communication and education. In contrast, a significant number of studies have also reported conflicting results regarding comparative clinical outcomes and have highlighted other limitations regarding the adoption of videolaryngoscopy in routine obstetric care. Nevertheless, considering the peculiarities of obstetric intubation, the Macintosh-style videolaryngoscope can be suggested as the primary intubation device as it offers the benefits of both videolaryngoscopy and direct laryngoscopy. However, more rigorous evidence is needed to clarify the current blind spots and controversies regarding the role of videolaryngoscopy in obstetrics.

Comparison of modified anterior and traditional posterior accesses for ultrasound-guided superior laryngeal nerve block in awake endotracheal intubation: study protocol for a randomised non-inferiority clinical trial

IntroductionAwake tracheal intubation (ATI) involves placing a tracheal tube in an awake, spontaneously breathing patient. Superior laryngeal nerve block (SLNB) can effectively abolish the glottic closure reflex, and blunt the...

A Randomized Study of Rigid Video Stylet versus Macintosh Laryngoscope for Double-Lumen Endobronchial Tube Intubation Assistance in Thoracoscopic Pulmonary Surgery.

Double-lumen endobronchial tube (DLT) intubation is more challenging than single-lumen tube intubation is, and the rigid video stylet (RVS) is one of the tools that has emerged to deal with this demanding intubation procedure. We evaluated whether the UE® RVS can shorten the DLT intubation time and improve the first-attempt intubation success rate compared with that of Macintosh laryngoscope (ML). A total of 130 participants scheduled to undergo thoracoscopic pulmonary surgeries were enrolled. They were randomized to receive either ML- or RVS-assisted DLT intubation. The primary outcomes were the intubation time and first-attempt intubation success rate. The secondary outcomes were the overall intubation success rate, mean arterial pressure, postoperative sore throat (POST), and postoperative hoarseness at 1 h and 24 h. Compared with the ML group, the intubation time was significantly shorter in the RVS group (p &lt; 0.001; 30.82 ± 10.61 vs. 39.62 ± 6.54 s), however, the first-attempt success rate was significantly lower (p = 0.048; 83.08% vs. 95.16%). The POST at 1 h was less severe in the RVS group (p = 0.021). No significant differences were found for the other indicators. Among the patients with normal airways, the UE® RVS can achieve faster DLT intubation and decrease the severity of a POST at 1 h, although it was associated with a lower first-attempt intubation success rate.

Direct versus video laryngoscopy with standard blades for neonatal and infant tracheal intubation with supplemental oxygen: a multicentre, non-inferiority, randomised controlled trial

Tracheal intubation in neonates and infants is a potentially life-saving procedure. Video laryngoscopy has been found to improve first-attempt tracheal intubation success and reduce complications compared with direct laryngoscopy in children younger than 12 months. Supplemental periprocedural oxygen might increase the likelihood of successful first-attempt intubation because of an increase in safe apnoea time. We tested the hypothesis that direct laryngoscopy is not inferior to video laryngoscopy when using standard blades and supplemental oxygen is provided. We did a non-inferiority, international, multicentre, single-blinded, randomised controlled trial, in which we randomly assigned neonates and infants aged up to 52 weeks postmenstrual age scheduled for elective tracheal intubation to either direct laryngoscopy or video laryngoscopy (1:1 ratio, randomly assigned using a secure online service) at seven tertiary paediatric hospitals across Australia, Canada, Italy, Switzerland, and the USA. An expected difficult intubation was the main exclusion criteria. Parents and patients were masked to the assigned group of treatment. All infants received supplemental oxygen (1 L/Kg per min) during laryngoscopy until the correct tracheal tube position was confirmed. The primary outcome was the proportion of first-attempt tracheal intubation success, defined as appearance of end-tidal CO2 curve at the anaesthesia monitor, between the two groups in the modified intention-to-treat analysis. A 10% non-inferiority margin between direct laryngoscopy or video laryngoscopy was applied. The trial is registered with ClinicalTrials.gov (NCT04295902) and is now concluded. Of 599 patients assessed, 250 patients were included between Oct 26, 2020, and March 11, 2022. 244 patients were included in the final modified intention-to-treat analysis. The median postmenstrual age on the day of intubation was 44·0 weeks (IQR 41·0-48·0) in the direct laryngoscopy group and 46·0 weeks (42·0-49·0) in the video laryngoscopy group, 34 (28%) were female in the direct laryngoscopy group and 38 (31%) were female in the video laryngoscopy group. First-attempt tracheal intubation success rate with no desaturation was higher with video laryngoscopy (89·3% [95% CI 83·7 to 94·8]; n=108/121) compared with direct laryngoscopy (78·9% [71·6 to 86·1]; n=97/123), with an adjusted absolute risk difference of 9·5% (0·8 to 18·1; p=0·033). The incidence of adverse events between the two groups was similar (-2·5% [95% CI -9·6 to 4·6]; p=0·490). Post-anaesthesia complications occurred seven times in six patients with no difference between the groups. Video laryngoscopy with standard blades in combination with supplemental oxygen in neonates and infants might increase the success rate of first-attempt tracheal intubation, when compared with direct laryngoscopy with supplemental oxygen. The incidence of hypoxaemia increased with the number of attempts, but was similar between video laryngoscopy and direct laryngoscopy. Video laryngoscopy with oxygen should be considered as the technique of choice when neonates and infants are intubated. Swiss Pediatric Anaesthesia Society, Swiss Society for Anaesthesia and Perioperative Medicine, Foundation for Research in Anaesthesiology and Intensive Care Medicine, Channel 7 Telethon Trust, Stan Perron Charitable Foundation, National Health and Medical Research Council.

Prewarming non-inflatable cuff laryngeal mask for mechanical ventilation: A systematic review and meta-analysis with trial sequential analysis.

Non-inflatable cuff laryngeal masks are generally composed of thermoplastic material. The thermoplastic nature of the non-inflatable cuff will become soft and match the laryngeal anatomy better as it reaches body temperature after intubation. This meta-analysis aims to evaluate the clinical validity of prewarming non-inflatable cuff laryngeal mask before insertion. We searched PubMed, Cochrane Library, Embase, Web of Science, Ovid Medline, CNKI, Wan Fang Database and VIP Database to find randomized controlled trials (RCTs) researching the clinical validity of prewarming non-inflatable cuff laryngeal mask. The retrieval time is up to June 2022. Articles published in the English and Chinese languages were considered. Quality assessment was conducted with the Cochrane Collaboration's tool and GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. Subgroup analyses and trial sequential analysis (TSA) were performed to control the risk of random errors. Publication bias was assessed by funnel plots and Egger's regression test. The outcomes included sealing pressure immediately after successful ventilation, the first-attempt intubation success rate and the incidence of postoperative pharyngeal pain. Eight RCTs evaluating 683 patients were identified. Pooled results showed that compared to the control group, prewarming non-inflatable cuff laryngeal mask provided a higher sealing pressure immediately after successful ventilation (mean difference: 1.73 cm H2O; 95% confidence interval [CI]: 0.95-2.52; P < .0001; I2 = 16; high quality), higher first-attempt intubation success rate (risk ratio [RR]: 1.05; 95% CI: 1.01-1.09; P = .01; I2 = 26%; high quality, number needed to treat [NNT] = 22 [95% CI 12.5-100]) and lower incidence of postoperative pharyngeal pain (RR: 0.59, 95% CI: 0.46-0.75; P < .0001; I2 = 0; high quality, NNT = 6 [95% CI 4.17-9.09]). The results were confirmed by TSA. Prewarming non-inflatable cuff laryngeal mask could provide better mechanical ventilation efficiency with higher sealing pressure, a higher first-attempt intubation success rate and a lower incidence of postoperative pharyngeal pain. PROSPERO CRD42021245350.

Impact of Macintosh blade size on endotracheal intubation success in intensive care units: a retrospective multicenter observational MacSize-ICU study

PurposeTo investigate the impact of Macintosh blade size used during direct laryngoscopy (DL) on first-attempt intubation success of orotracheal intubation in French intensive care units (ICUs). We hypothesized that success rate would be higher with Macintosh blade size No3 than with No4.MethodsMulticenter retrospective observational study based on data from prospective trials conducted in 48 French ICUs of university, and general and private hospitals. After each intubation using Macintosh DL, patients’ and operators’ characteristics, Macintosh blade size, results of first DL and alternative techniques used, as well as the need of a second operator were collected. Complications rates associated with intubation were investigated. Primary outcome was success rate of first DL using Macintosh blade.ResultsA total of 2139 intubations were collected, 629 with a Macintosh blade No3 and 1510 with a No4. Incidence of first-pass intubation after first DL was significantly higher with Macintosh blade No3 (79.5 vs 73.3%, p = 0.0025), despite equivalent Cormack–Lehane scores (p = 0.48). Complications rates were equivalent between groups. Multivariate analysis concluded to a significant impact of Macintosh blade size on first DL success in favor of blade No3 (OR 1.44 [95% CI 1.14–1.84]; p = 0.0025) without any significant center effect on the primary outcome (p = 0.18). Propensity scores and adjustment analyses concluded to equivalent results.ConclusionIn the present study, Macintosh blade No3 was associated with improved first-passed DL in French ICUs. However, study design requires the conduct of a nationwide prospective multicenter randomized trial in different settings to confirm these results.

Initial clinical experience of the MedAn videolaryngoscope with the Nishikawa blade

BackgroundThe MedAn videolaryngoscope with the Nishikawa blade has been designed to make videolaryngoscopy and tracheal intubation safer and more successful. AimWe aimed to preliminarily evaluate the performance of this new videolaryngoscope system for routine tracheal intubation at a teaching hospital. MethodsA total of 243 patients with apparently normal airways scheduled for elective surgery under general anesthesia were randomly assigned to the consultant or trainee group according to the actual operation schedule. Video clips of videolaryngoscopic intubation were recorded to analyze the relevant parameters. The primary outcome was the first-attempt intubation success rate. The secondary outcomes included the total time to successful intubation (laryngoscopy and intubation times) on the first attempt and recorded soft tissue injury. ResultsThe first-attempt intubation success rate was 98.8% (240/243). The median total time to intubation on the first attempt was 26.0 s, and it was longer in the trainee group than in the consultant group (median, 28.0 vs. 23.0 s, p < 0.001). Soft tissue injury was not observed. ConclusionThe MedAn videolaryngoscope with the Nishikawa blade can provide an excellent laryngeal view and sufficient intubation pathway for safe, easy, and effective intubation in patients with apparently normal airways.

Neonatal Simulation Program: A 5 Years Educational Journey From Qatar.

We describe the process of implementation, adaptation, expansion and some related clinical intuitional impacts of the neonatal simulation program since its launch in 2016 in a non-simulation neonatal unit. The team has developed 6 types of curricula: 1 full-day course and 5 half-day workshops. A total of 35 free of charge simulation courses/workshops were conducted, 32 in Qatar and 3 abroad with a total of 799 diverse participants. There was a steady increase in the overall success rate of PICC insertion from 81.7% (309/378) to 97.6% (439/450) across 3 years (P < 0.0001). The first attempt PICC insertion success rate has been also increased from 57.7% (218/378) to 66.9% (301/450) across 3 years. The mean duration of PICC insertion has been improved from 39.7 ± 25 to 34.9 ± 12.4 min after implementing the program (P = 0.33). The mean duration of the LISA catheter insertion at the beginning of the workshop was 23.5 ± 15.9 compared to 12.1 ± 8.5 s at the end of the workshop (P = 0.001). When it came to clinical practise in real patients by the same participants, the overall LISA catheter insertion success rate was 100% and the first attempt success rate was 80.4%. The mean duration of LISA catheter insertion in real patients was 26.9 ± 13.9 s compared to the end of the workshop (P = 0.001). The mean duration of the endotracheal intubation at the beginning of the workshop was 12.5 ± 9.2 compared to 4.2 ± 3.8 s at the end of the workshop (P = 0.001). In real patients, the first-attempt intubation success rate has been improved from 37/139 (26.6%) in the first year to 141/187 (75.5%) in the second year after the program implementation (P = 0.001). The mean duration of successful endotracheal intubation attempts has been improved from 39.1 ± 52.4 to 20.1 ± 9.9 s (P = 0.78). As per the participants, the skills learned in the program sessions help in protecting neonates from potential harm and improve the overall neonatal outcome. Implementing a neonatal simulation program is a promising and feasible idea. Our experience can be generalised and replicated in other neonatal care institutions.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Diabetes Mellitus Olan Hastalarda C-MAC Video Laringoskop ve Macintosh Laringoskopun Elektif Trakeal Entübasyon İçin Karşılaştırılması: Randomize Kontrollü Çalışma

Objective: C-MAC video laryngoscope and Macintosh direct laryngoscope were compared in terms of intubation conditions, during elective tracheal intubation in patients with diabetes mellitus (DM) who have a high risk for difficult airway. Material and Methods: One hundred and ten American Society of Anesthesiologist physical class II-III patients with DM undergoing elective surgery were randomized to be intubated using C-MAC video laryngoscope or Macintosh laryngoscope. Glottic view Cormack Lehane (CL) score, intubation time, intubation difficulty scale (IDS) score, and first attempt intubation success were compared. Results: Similar intubation times were detected [Macintosh laryngoscope: 39.6±30.1 seconds; C-MAC: 46.7±35.4 seconds (p=0.098). C-MAC provided significantly better CL scores]. Grade 1 CL laryngeal view was observed in 37 (68%) C-MAC vs. 26 (47.3%) Macintosh laryngoscope intubations (p=0.04). An IDS score of >5 was determined in 11 (20.4%) patients with C-MAC and in 10 (18.2%) with Macintosh laryngoscope (p=0.04), indicating an overall 20.1% moderate-to-severe intubation difficulty (p=0.536). The mean IDS score was 3.2±2.9 and 2.4±3.3 with C-MAC and Macintosh laryngoscopes, (p=0.04). First-attempt intubation success was 83.3% vs. 87.0% with C-MAC vs. Macintosh laryngoscope (p=0.786). Conclusion: In patients with DM, CMAC provided improved glottis visualization, similar intubation time and first-attempt intubation success as a first-attempt intubation device compared with the Macintosh laryngoscope. However IDS scores were higher with the C-MAC. The incidence of actual intubation difficulty was found 20.1% in this diabetic study population.

Comparison of self-assembled video laryngoscope versus McGrath MAC®: A randomised controlled trial.

ABSTRACTBackground and Aims:Video laryngoscopy highly improves the success rate for endotracheal intubation. However, commercially available video laryngoscopes such as McGrath MAC® can be costly. An economical video laryngoscope was assembled by attaching a fibreoptic videoscope into a Macintosh laryngoscope. This randomised study aimed to compare the intubation time of this self-assembled modified Macintosh video laryngoscope (SAM-VL) and McGrath MAC® (McGrath).Methods:This study enroled 62 adults scheduled for elective surgery under general anaesthesia with endotracheal intubation. The primary outcome was total intubation time. Secondary outcomes were the time for glottic visualisation (time A), time for tube insertion after glottic visualisation (time B), first-attempt intubation success rate, degree of glottic visualisation, and need for backward, upward, rightward pressure (BURP) assistance, complications, and user satisfaction. The tests used were: Kolmogorov-Smirnov and the Mann-Whitney test to analyse the data’s distribution and the primary outcome, respectively.Results:The median total intubation time in the SAM-VL group versus the McGrath was 63 s (27–114s) versus 74 s (40–133s), respectively (P = 0.032). Intubation time B was significantly faster, while the score of glottic visualisation and BURP assistance was significantly higher in the SAM-VL group. The differences in the rate of successful first attempts and complications were not statistically significant. SAM-VL users rated the ease of blade insertion and manoeuvrability, degree of glottic visualisation, and overall rating as very high.Conclusion:Endotracheal intubation using self-assembled modified video laryngoscope is faster and allows better glottis visualisation than McGrath MAC®.