Glottic View Research Articles

Analysis of the airway registry from an academic emergency department in South Africa.

Airway management is an essential skill for doctors working in the emergency department (ED). Safety and efficacy are crucial to its success. Analysis of an airway registry can provide feedback that can be used for quality improvement purposes. To examine the first airway registry from an ED in South Africa (SA), a low- to middle-income country (LMIC), and compare the findings with international data. A retrospective analysis of 13 months' data from the airway registry of an academic ED with an annual census of 60 000 patients. Data analysed included demographics, indications for intubation, intubator training level, type of intubation device, number of attempts, adverse events, pre-oxygenation methods, and drug and intravenous fluid use. A total of 321 intubations were included. The majority of the patients (71.6%) had non-traumatic indications for intubation. The overall first-pass intubation success (FPS) rate for doctors was 81.8%. Although this rate is lower than the mean rate suggested in an international meta-analysis (84.1%), it is within the 95% confidence interval (80.1 - 87.4%). Overall FPS rates showed no difference between video laryngoscopy (81.7%) compared with direct laryngoscopy (73.3%) (p-value 0.079), although better glottic views were obtained with video laryngoscopy (80.5% were Cormack-Lehane grade 1). Analysis of pre-oxygenation methods found that although sicker patients had received more aggressive pre-oxygenation, e.g. with non-invasive or bag-mask ventilation techniques, they still desaturated more often (35.8% and 62.5%, respectively) than less sick patients who received simple non-rebreather facemask pre-oxygenation (4.5%). This analysis of the first airway registry from an SA ED highlights that airway management in an LMIC can be performed on par with accepted international standards. It serves as a good baseline for further research into airway management in other LMICs and provides useful feedback for quality improvement purposes.

Trialing a novel intubation equipment: A bidirectional tube with a flexible video stylet

BackgroundVideo-laryngoscopy has proven valuable in management and training of difficult airways. We evaluate the Yann tube, a novel bi-directional articulable endotracheal tube and video stylet combination, together with video-laryngoscopy in a simulation setting to determine if it improves management and education of difficult airways. MethodsWe evaluated the Yann tube (with video-laryngoscopy) against direct and video-laryngoscopy alone across four simulated airway scenarios, and measured time and attempts to successful intubation, percentage-of-glottic-opening (POGO) score, and Cormack-Lehane grading. Afterward, we surveyed participant subjective experiences. ResultsThere were 32 participants of varying experience. Pharyngeal obstruction was the only airway scenario where the Yann tube was significantly slower than video-laryngoscopy alone (37s vs 27s; p < 0.01), in exchange for improved glottic views, regarding POGO (75.2% vs 56.4%; p < 0.05) and Cormack-Lehane (1.4 vs 1.9; p < 0.01) scores. Students reported significantly greater confidence with intubation and airway anatomy understanding after simulation (p < 0.001). ConclusionsAlthough the Yann tube did not significantly improve successful first pass intubation, it did not significantly take longer to perform, and improved airway visualization in certain difficult airway scenarios. The use of simulation also enhanced education and understanding of airway anatomy for novice intubators.

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

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

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

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

Tracheal intubation using the Airtraq video laryngoscope vs. Macintosh laryngoscope in patients with anticipated difficult intubation

BackgroundVarious types of laryngoscopes have been invented to ameliorate the laryngoscopic view of the glottis, in normal and difficult airway, which helps anaesthesiologists to secure the airway during anaesthesia. In this prospective study, we aimed to compare the efficacy of the Airtraq video laryngoscope (AVL) and the Macintosh curved-blade laryngoscope (MBL), by using a common clinical assessment tool in patients with modified Mallampati class III and IV. MethodsA total of 60 patients [group A (AVL) and group M (MBL)] with modified Mallampati class III and IV listed for general anaesthesia were included. Each patient was intubated with either of the laryngoscope based on the group allotted. Time taken for tracheal intubation, grade of visualisation of glottis and need for manoeuvres to optimise the glottic view were compared. ResultsThe degree of the glottic view during successful intubation attempt was easily appreciated in group A (p < 0.0001). Difference in the requirement of manoeuvres for optimising the laryngeal view/assisting in intubation as assessed by manoeuvre score was easily appreciated in group A (p < 0.010). Rise in heart rate and mean arterial pressure 1 and 2 min after intubation was more in group M than in group A (p < 0.0001). No event of any airway trauma, as evidenced by visible trauma to lips or oral mucosa or blood on laryngoscope, was observed with either of the laryngoscope. ConclusionThe novel AVL provides better intubation conditions with greater ease of intubation, better glottic view and lesser haemodynamic alterations during laryngoscopy than MBL.

The "BURP" maneuver improves the glottic view during laryngoscopy but remains a difficult procedure.

ObjectiveWe investigated the “BURP” maneuver’s effect on the association between difficult laryngoscopy and difficult intubation, and predictors of a difficult airway.MethodsAdult patients who underwent general anesthesia and tracheal intubation from September 2016 to May 2018 were included. The “BURP” maneuver was performed when glottic exposure was classified as Cormack–Lehane grade 3 or 4, suggesting difficult laryngoscopy. The thyromental distance, modified Mallampati score, and interincisor distance were assessed before anesthesia.ResultsAmong this study’s 2028 patients, the “BURP” maneuver decreased difficult laryngoscopies from 428 (21.1%) to 124 (6.1%) cases and increased the difficult intubation to difficult laryngoscopy ratio from 53/428 (12.4%) to 52/124 (41.9%). For laryngoscopies classified as difficult without the “BURP” maneuver, the area under the curve (AUC) of the thyromental distance, modified Mallampati score, and interincisor distance was 0.60, 0.57, and 0.66, respectively. In difficult laryngoscopies using the “BURP” maneuver, the AUC of the thyromental distance, modified Mallampati score, and interincisor distance was 0.71, 0.67, and 0.76, respectively.ConclusionsThe “BURP” maneuver improves the laryngoscopic view and assists in difficult laryngoscopies. Compared with difficult laryngoscopies without the “BURP” maneuver, those with the “BURP” maneuver are more closely associated with difficult intubations and are more predictable.Trial registration: www.chictr.org.cn identifier: ChiCTR-ROC- 16009050.

A randomized controlled study on the visual grading of the glottis and the hemodynamics response to laryngoscopy when using I-View and MacGrath Mac videolaryngoscopes in super obese patients.

Videolaryngoscopes improve visualization of glottic in morbidly obese patients. Super-obesity is one of the risk factors influencing probability of difficult mask ventilation and difficult intubation. Super-obese (BMI > 50kg/m2) patients should be intubated either with fiberscope awake intubation or with video laryngoscopes. In prospective observational study we decided to compare glottis view during intubation using I-view and McGrath Mac videolaryngoscopes in super obese patients. Patients were randomly allocated into group M (McGrath Mac) or group I (I-View). Obtained view was analyzed regarding POGO (Percentage Of Glottis Opening) scale and the necessity to use of additional aid like intubation stylet was recorded. Hemodynamic response to videolaryngoscopy was assessed. As results POGO score was better in group M when compared to group I: 81.66 ± 22.8% vs 96.66 ± 7.24% (p = 0.0132) in I and V groups respectively. The use of intubation stylet was similar in both groups. The hemodynamic response to videolaryngoscopy was similar between groups. The POGO score was better for McGrath Mac than for I-view videolaryngoscope, however, both devices allowed for safe and effective intubation in super-obese patients. The hemodynamic response to videolaryngoscopy was similar between devices.

Ease of Intubation While Using Macintosh and (Mccoy’s Type) Laryngoscope Blade Undergoing with Anaesthesiology

Various anesthesia devices have been designed to overcome the difficult airway scenario in anesthesia practice. The ease of intubation, timing, and hemodynamic variability between the two groups during intubation are considered as primary results compare. The study was conducted in two groups, each group set aside of 65 patients, named Group A and Group B with normal physical status I-II to endothelial intubation. Determined to perform surgery under anesthesia by consent. This includes simple rigid laryngoscopes for complex fiber-optic incubating devices; However, there is weak evidence to support the superiority of one device over another. McCoy’s blade shows overall minimal haemodynamic response and provides better glottic view and ease of intubation as compared to Macintosh blade.

Ramped versus sniffing position for tracheal intubation: A systematic review and meta-analysis.

Whether the ramped or sniffing laryngoscopy position is better for tracheal intubation is unclear. This study aimed to determine the efficacy and safety of tracheal intubation in the ramped versus sniffing position. We conducted a systematic review and meta-analysis of randomized clinical trials to compare the ramped position with the sniffing position for tracheal intubation. We searched the databases of Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Excerpta Medica Database (Embase), ClinicalTrials.gov, and World Health Organization Clinical Trials Registry Platform up to December 2018. We included randomized-controlled trials, trials of participants who required tracheal intubation in any setting, and that compared tracheal intubation in the ramped and the sniffing positions. Two authors independently screened the trials, extracted the data, and assessed the risk of bias. We conducted the meta-analysis using the random-effects model to calculate the pooled risk ratio with 95% confidence interval. Of the 2631 titles/abstracts screened, three studies (representing 513 patients) were included in the meta-analysis. The pooled risk ratio with 95% confidence interval (CI) of the sniffing versus the ramped position was as follows: a first successful attempt, 0.97 (95% CI, 0.86-1.09; I2=55%); laryngoscopy attempts ≤2, 1.08 (95% CI, 0.88-1.31; I2=93%); and good glottic view with Cormack-Lehane grade≤2, 0.86 (95% CI, 0.69-1.07; I2=86%). This systematic review and meta-analysis indicated no favorable aspects of the ramped position as compared to the sniffing position. Thus, further research is warranted to identify which is better in tracheal intubation. PROSPERO identifier, CRD42019116819.

VivaSight single-lumen tube as an intubation method. A systematic review and meta-analysis of randomised simulation trials

INTRODUCTION: Endotracheal intubation is one of the basic procedures performed in emergency medicine in patients with respiratory insufficiency, inability to maintain airway patency, or apnoea. Rapid performance of the procedure and implementation of ventilation are among the basic principles of rescue procedures. The primary aim of the present systematic review and meta-analysis was to compare the VivaSight SL tube-mounted camera with a standard endotracheal single-lumen tube and direct laryngoscope for endotracheal intubation based on randomised controlled trials of simulation or cadaver trials. The analysis was based on the hypothesis that the use of videolaryngoscopy based on VivaSight SL tube increases the effectiveness of endotracheal intubation, reducing the risk of ineffectiveness of the first intubation attempt and the risk of adverse events, such as dental compression. MATERIAL AND METHODS: We searched the MEDLINE, EMBASE, Scopus, Cochrane, and Google Scholar databases for randomised, controlled trials and observational studies from 1985 until October 2019, without language restrictions. Grey literature, clinicaltrials.gov, and reference lists of articles were hand searched. We conducted a meta-analysis with random-effects models to evaluate time to intubation, first-pass success rates, overall success rates, dental compression, and glottic view. RESULTS: The search located 12 eligible studies. The time of intubation using VivaSight was significantly shorter than that of direct laryngoscopy (MD = –11.29 [–13.10, –9.49], p < 0.001). The efficacy of the first intubation attempt was higher for VivaSight than for DL (96.0% vs. 61.7%; RR = 1.62 [1.40, 1.88], p < 0.001). The meta-analysis showed that the total efficacy of VivaSight intubation compared to direct laryngoscopy was statistically significantly higher (100% vs. 88.9%, RR = 1.11 [1.02, 1.20]; p = 0.02). The glottis visibility assessed as Cormack-Lehane grade I or II was better in VivaSight intubation compared to direct laryngoscopy (100% vs. 90.9%, RR = 1.05 [0.99, 1.12]; p = 0.08). CONCLUSIONS: Our meta-analysis suggests that the VivaSight SL provided better glottic visualisation and shorter intubation time, with improved success rates during different simulated intubation scenarios.

Comparison of videolaryngoscopy and direct laryngoscopy by German paramedics during out-of-hospital cardiopulmonary resuscitation; an observational prospective study

BackgroundVideolaryngoscopy (VL) has become a popular method of intubation (ETI). Although VL may facilitate ETI in less-experienced rescuers there are limited data available concerning ETI performed by paramedics during CPR. The goal was to evaluate the impact VL compared with DL on intubation success and glottic view during CPR performed by German paramedics. We investigated in an observational prospective study the superiority of VL by paramedics during CPR compared with direct laryngoscopy (DL).MethodsIn a single Emergency Medical Service (EMS) in Germany with in total 32 ambulances paramedics underwent an initial instruction from in endotracheal intubation (ETI) with GlideScope® (GVL) during resuscitation. The primary endpoint was good visibility of the glottis (Cormack-Lehane grading 1/2), and the secondary endpoint was successful intubation comparing GVL and DL.ResultsIn total n = 97 patients were included, n = 69 with DL (n = 85 intubation attempts) and n = 28 VL (n = 37 intubation attempts). Videolaryngoscopy resulted in a significantly improved visualization of the larynx compared with DL. In the group using GVL, 82% rated visualization of the glottis as CL 1&2 versus 55% in the DL group (p = 0.02). Despite better visualization of the larynx, there was no statistically significant difference in successful ETI between GVL and DL (GVL 75% vs. DL 68.1%, p = 0.63).ConclusionsWe found no difference in Overall and First Pass Success (FPS) between GVL and DL during CPR by German paramedics despite better glottic visualization with GVL. Therefore, we conclude that education in VL should also focus on insertion of the endotracheal tube, considering the different procedures of GVL.Trial registrationGerman Clinical Trial Register DRKS00020976, 27. February 2020 retrospectively registered.

Direct versus indirect laryngoscopy using a Macintosh video laryngoscope: a mannequin study comparing applied forces.

Upper airway injury and sympathetic activation may be related to the forces applied during laryngoscopy. We compared the applied forces during laryngoscopy using direct and indirect visualization of a standardized mannequin glottis. Force transducers were applied to the concave surface of a GlideScope T-MAC Macintosh-style video laryngoscope that can also be used as a conventional direct-view laryngoscope. Thirty-four anesthesiologists performed four laryngoscopies (two direct and two indirect views) on an Ambu mannequin in a randomized sequence. During each laryngoscopy, participants were instructed to obtain views corresponding to > 80% and 50% of the glottic opening aperture. Peak and impulse forces were measured for each view. To achieve a 50% glottic opening view, the top 10th percentile force was higher with direct vs indirect laryngoscopy in terms of peak (difference, 9.1 newton; 99% confidence interval [CI], 7.4 to 13.9) and impulse (difference, 56.4 newton·sec; 99% CI, 49.0 to 81.7) forces. To achieve >80% view of the glottic opening, median force was higher with direct vs indirect laryngoscopy in terms of peak (difference, 3.6 newton; 99% CI, 1.6 to 7.3) and impulse (difference, 20.4 newton·sec; 99% CI, 11.7 to 35.1) forces. In this mannequin study, lower forces applied during indirect vs direct laryngoscopy may reflect an advantage of video laryngoscopy, but additional studies using patients are required to confirm the clinical implications of these findings.

COMPARATIVE STUDY OF TRUVIEW EVO2 LARYNGOSCOPE WITH MACINTOSH LARYNGOSCOPE FOR LARYNGOSCOPY AND INTUBATION IN ADULTS RECEIVING GENERAL ANAESTHESIA FOR ELECTIVE SURGERIES

INTRODUCTION: Though macintosh laryngoscope is a standard for intubation, new laryngoscopes are being introduced to reduce the disadvantages of macintosh. Trueview EVO2 laryngoscope has some advantages over macintosh laryngoscope. MATERIALAND METHODS: For this randomized, prospective study, 60 patients were allocated to either of the two groups and laryngoscopy and endotracheal intubation done in Group A by macintosh laryngoscope and in Group B by truview EVO2 laryngoscope. The time taken for intubation, number of intubation attempts, POGO score., Cormack-lehane grading, rescue technique for intubation, haemodynamics and side effects were studied RESULTS: POGO score of 100% was seen in maximum number of patients in group B compared to group A. Cormack lehane grade I was seen in maximum number of patients in group B Number of attempts taken were more in group B and statistically signicant. Rescue technique like use of bougie, external pressure were used more in group A compared to group B. Mean time for laryngeal intubation was more in group B compared to group A. Haemodynamics were comparable between the groups. Minor complications seen and they were comparable. CONCLUSION: Truview EV02 laryngoscopy is associated with improved view of glottis , stable hemodynamic parameters, less complications but at the cost of longer intubation time and increase number of attempts compared to Macintosh laryngoscope .

Microlaryngeal surgery, difficult airway and a missing throat pack: C Mac D-blade to the rescue!

Skilful use of the C Mac D-blade videolaryngoscope, with preservation of spontaneous respiration, can avert preoperative tracheostomy and guide microlaryngeal surgery (MLS) tube insertion in patients with large growths obliterating glottic view. The long narrow stylet accompanying double-lumen tubes can be used for D-Blade guided MLS tube orotracheal intubation. A definite protocol for safe insertion and removal of throat packs has been described here. Throat packs may go missing despite following protocols. Our algorithm includes visual and documentary precautions and means of exploration of missing throat packs. D-blade is invaluable in scanning the oropharynx in event of a lost throat pack.

In Response.

We read with great interest the letter by Priebe1 regarding our review of the use of cricoid pressure (CP).2 While many of the points1 actually reiterate, not dispute, our original conclusions, we again underscore the purpose for our review, stated clearly in our opening paragraph: “[w]e therefore review the available scientific [emphasis added] evidence of the effectiveness and safety of CP…”. We are well aware that clinical care standards vary immensely.2 We also recognize that Germany has largely abandoned CP use in clinical practice3,4 and that the author himself is a strong advocate against CP use.5 Alternatively, other experts strongly defend this procedure.6 One issue that requires clarification is Priebe’s reference to the Sellick Interest in Rapid Sequence Induction (IRIS) randomized trial and the intubation difficulty posed by CP.7 We reanalyzed the original IRIS trial data of Cormack-Lehane scores. We used χ2 test, which yields significant P values in large sample sizes.8 We herein report Cramer’s V of 0.09 as the strength of association measure,9 suggesting a weak association between CP and higher Cormack-Lehane scores. Moreover, operators were asked to release CP in only 14% of CP cases and in 5% of sham group, improving the glottic view in 62% and 33% of cases, respectively.7 The sham group reported improvement in Cormack-Lehane score after sham interruption,7 likely reflecting the assessors’ anticipation of CP use. We suggest that most of the experienced operators could detect CP at laryngoscopy, while the sham itself is likely to be readily guessed (more frequently than by chance) by the operators, making them more likely to report an improved view after its release. In clinically relevant outcomes, the groups did not differ in the number of attempts at intubation or arterial oxygen desaturation, and median intubation times were similar (27 seconds in CP group and 23 seconds in sham group); a 4-second difference is statistically significant7 but not clinically relevant.10 The IRIS trial concluded, “… the interference of the CP with airway control has previously been overestimated.” Moreover, a “…significant increase in the incidence of difficult tracheal intubation…” was not observed, as Priebe1 suggested. From an evidence-based medicine point of view, the IRIS (noninferiority) study7 was severely underpowered. This limitation is acknowledged in the accompanying editorial: “the noninferiority of withholding CP could not be proven because of the overall lower-than-expected incidence of aspiration.”11 Therefore, there is no evidence-based foundation for the selective (and likely erroneous) interpretation, “the study nevertheless documents lack benefit of the application of CP with simultaneous interference with optimal airway management.”1 Alternatively, we would be remiss if we did not also acknowledge study’s tremendous value, as it is the first study granted ethical permission not to use CP during rapid sequence intubation in patients. We continue to recommend that investigators use previous findings effectively in planned research designs, and include generally accepted indicators such as percent of glottic opening score,12,13 upper lip bite test (which has the highest sensitivity for diagnosing difficult laryngoscopy),14 and modified Mallampati test (which has the highest sensitivity for diagnosing difficult tracheal intubation),14 none of which were used in the IRIS study.7 With strong opinions on either side of the argument,1,6 we believe we provided a balanced review of current evidence on CP use, and we are not surprised that our article2 incited controversy. We sincerely hope the debate will galvanize future researchers to provide definitive evidence that can then be translated into guidelines, rather than the consensus opinions that drive current clinical care. Marko Zdravkovic, MDDepartment of Anaesthesiology,Intensive Care and Pain ManagementUniversity Medical Centre MariborMaribor, SloveniaFaculty of MedicineMaribor, Slovenia Mark J. Rice, MDDepartment of AnesthesiologyVanderbilt University Medical CenterNashville, Tennessee Sorin J. Brull, MD, FCARCSI (Hon)Department of Anesthesiology and Perioperative MedicineMayo Clinic College of Medicine and ScienceJacksonville, Florida[email protected]

A Step Ahead for Difficult Airway Management Using GlideScope®: A Prospective, Randomised, Comparative Study

Background and Aim: Different techniques have been developed in order to optimise the practice of intubation with GlideScope® (Verathon Inc, Bothell, Washington, USA) video-assisted laryngoscope. This study aimed to demonstrate the use of a new, safe, and effective technique by inserting both the video-assisted laryngoscope blade and endotracheal tube (ETT) together. Methods: A prospective, randomised study was conducted with 50 patients who were anticipated as difficult for endotracheal intubation, aged 18–90 years, with an American Society of Anesthesiologists’ (ASA) classification of Grades I–IV, and who presented for elective surgery. The patients were divided into 2 groups of 25 participants: an intubation with traditional GlideScope (TG) technique group, and combined GlideScope (CG) and ETT simultaneous insertion group. The optimal glottic view and the time-to-intubation were recorded. Postintubation airway trauma and both practitioners’ and patients’ satisfaction were documented. The categorical data are presented as a number and percentage and were subjected to Fisher’s exact or Chi-square test for analysis. The statistical significance was p≤0.05. Results: The optimal glottic view was 64% in TG and 72% in CG (p=0.216); intubation was achieved within ≤15 secs in 22 patients in TG and all patients in CG (p=0.077); and 88% of patients in TG showed high satisfaction scores compared to 92% in CG (p=0.646). The practitioners’ satisfaction was 76% in TG and 96% in CG (p=0.042). Conclusion: Simultaneous insertion of both the GlideScope blade and ETT could provide fast, effective, and safe endotracheal intubation.

Comparison of glottic visualisation through supraglottic airway device (SAD) using bronchoscope in the ramped versus supine 'sniffing air' position: A pilot feasibility study.

Background and Aims:Airway management in obese patients is associated with increased risk of difficult airway and intubation. After failed intubation, supraglottic airway-guided flexible bronchoscopic intubation (SAGFBI) may be required. It is uncertain whether SAGFBI is best performed in the ramped versus conventional supine “sniffing air” position. We conducted a feasibility study to evaluate the logistics of positioning, compared glottic views, and evaluated SAGFBI success rates.Methods:We conducted a prospective, pilot study in patients with a body mass index (BMI) 30–40 kg/m2 undergoing elective operations requiring tracheal intubation. All patients were placed in a ramped position. After induction, a supraglottic airway device (SAD) was inserted. A flexible bronchoscope was inserted into the SAD and a photograph of the glottic view taken. The patient was repositioned to the supine position. A second photograph was taken. SAGFBI was performed. Images were randomised and assessed by two independent anesthetists.Results:Of 17 patients recruited, 15 patients were repositioned successfully. There were no differences in glottic views observed in the two positions. SAGFBI was successful in 92.9% of patients (median time 91.5 s). Haemodynamic changes were noted in 42.7% of patients which resolved spontaneously.Conclusion:Our pilot study was completed within 5 months, achieved low dropout rate and protocol feasibility was established. SAGFBI was successfully and safely performed in obese patients, with a median time of 91.5 s. The time taken for SAGFBI was similar to awake intubation using FBI and videolaryngoscopy. Our study provided preliminary data supporting future, larger-scale studies to evaluate glottic views in the ramped versus supine positions.

Patient positioning and glottic visualisation: A narrative review

Optimal glottic view is a prerequisite for successful endotracheal intubation. Several factors such as height of pillow, head position, backup position and head-elevated laryngoscopy position (HELP) have been attributed to improve glottic view. This review of existing literature was conducted to summarise current evidence on the influence of different head positions on glottic view. The search engines used were PubMed, Cochrane Library, Google Scholar and ResearchGate. Keywords used for the search were sniffing position, HELP, backup position and glottic view. The two components of optimal sniffing position used traditionally for laryngoscopy include neck flexion of 35° and face-plane extension of 15° which is supposed to align three axes (oral, pharyngeal and laryngeal axes). Optimal height of pillow used to achieve sniffing position was found to be 9 cm. Since it is difficult to align all the three axes, the two-curve theory was proposed. Advantage of the sniffing position was questioned by various authors who projected the HELP and 25° backup position as better options. Our narrative review suggests that 25° backup and HELP position improves glottic view in comparison to supine sniffing position. To achieve alignment of external auditory meatus to the sternal notch, a small child required a small pillow, an older child or an adult required a bigger pillow and obese patients needed the ramped position/25° head-up position.

Midline versus paraglossal laryngoscopic approach using the Miller blade in small children: A randomised, controlled, cross-over study

Background: Airway management in children is different from that of adults and needs special consideration. Laryngoscopy in children with the Miller straight blade can be performed via midline (MID) or paraglossal (PGL) approach. This study aimed to find out whether there was any advantage of one approach over the other in small children. Patients and Methods: After obtaining parental consent and approval from the Institutional Ethical Committee, this randomised, controlled, cross-over study was conducted in 110 children aged 2–24 months belonging to the American Society of Anesthesiologists Physical Status I or II. Children scheduled for elective surgeries under general anaesthesia were allocated randomly into one of the following two groups: A (PGL/MID) or B (MID/PGL) with 55 patients in each group. Following induction of anaesthesia and neuromuscular blockade, laryngoscopy was performed in a cross-over manner with either the PGL or MID approach first. The tip of the blade was placed at the vallecula. Intubation was performed following the second laryngoscopy. Glottic views with and without optimal external laryngeal manipulation (OELM) and ease of intubation were observed. Data were analysed, and P

Comparison of the C-MAC D-Blade videolaryngoscope and direct laryngoscope in pediatric patients: Randomized controlled trial.

Endotracheal intubation is a key skill for clinicians and may be challenging in some patients due to various reasons. Nowadays, various kinds of videolaryngoscopes are available and usually used as a rescue device when direct laryngoscopy failed. Pediatric airway has some differences when compared with adults and may be challenging. This study aims to compare and evaluate C Mac D-Blade and commonly used Macintosh laryngoscope in pediatric patients. In this study, 56 pediatric patients, 5-10 years old (10-40 kgs) who had undergone elective surgery and need endotracheal intubation were included after obtaining ethical board approval and informed consent from parents. The patients were randomized into two equal groups for laryngoscopy and intubation by either with Macintosh laryngoscope or C Mac D-Blade videolaryngoscope. Glottic view, number of attempts, intubation time, any complications and hemodynamic variables were recorded. A value of p<0.05 was considered significant. In pediatric patients with unanticipated difficult airway, the mean intubation time was significantly shorter with C Mac D-Blade (21±9 and 41±7 seconds, respectively (p<0.001). The results of the two groups were similar concerning the remaining parameters. C Mac D-Blade videolaryngoscope shortened intubation time about twice when compared to Macintosh blade C Mac D-Blade videolaryngoscope, Videolaryngoscopes may be a good alternative for routine intubation, education and a rescue device for difficult intubation.