Intubation Difficulty Scale Research Articles

A Comparison of the Effectiveness of the McCoy Laryngoscope and the C-MAC D-Blade Video Laryngoscope in Obese Patients.

Background and Objective: Obesity is associated with difficult or failed intubation attempts, making general anesthesia challenging for anesthesiologists to perform. The purpose of this study was to evaluate and compare the efficacy of a McCoy laryngoscope and a C-MAC D-blade video laryngoscope for intubation in obese patients with a body mass index (BMI) ≥ 35 kg/m2. Methods: In total, 104 patients were randomly assigned to be intubated with a McCoy (McCoy group) or C-MAC D-blade video laryngoscope (C-MAC group). The primary outcome was intubation time. The secondary outcomes were vocal cord exposure time, vocal cord passage time, proportion of successful intubation, mask ventilation scale, intubation difficulty scale (IDS), percentage of glottis opening (POGO) score, and hemodynamic variables. Results: Although the intubation time did not significantly differ, the C-MAC group showed shorter vocal cord exposure times and a higher rate of successful vocal cord exposure within 5 s. The IDS value was significantly lower in the C-MAC group than in the McCoy group. The proportion of patients who required an increase in lifting force during laryngoscopy was higher in the McCoy group than in the C-MAC group, which may explain the difference in MAP between the groups. Conclusions: Both the McCoy laryngoscope and the C-MAC D-blade video laryngoscope were useful during the intubation of obese patients. The C-MAC D-blade video laryngoscope might be more useful for obese patients in terms of hemodynamic stability.

A Comparison of Tracheal Intubation Using Direct Laryngoscope and Video Laryngoscope in the Sellick and Trendelenburg Position with That Using Direct Laryngoscope in the Supine Sniffing Position: A Randomized Controlled Trial.

Background: Tracheal intubation in the Sellick and Trendelenburg position (ST position) can prevent pulmonary aspiration but increase the difficulty of tracheal intubation. We compared tracheal intubation using video and direct laryngoscopy in the ST position with direct laryngoscopy in the supine sniffing position to evaluate the overall intubation performance. Methods: One hundred and twenty patients were randomly assigned to three groups: direct laryngoscope in the supine sniffing position (control), direct laryngoscope in the ST position (ST direct), and video laryngoscope in the ST position (ST video). The primary outcome was the intubation time; secondary outcomes included the first attempt success rate of tracheal intubation, intubation difficulty scale score, operator's subjective assessment of intubation difficulty, and modified Cormack-Lehane grades. Results: The median intubation times were greater in the ST direct (36.0 s) and video (34.5 s) than the control (28.0 s) groups. The first attempt success rate decreased in the ST direct (77.5%) but not the video (95.0%) group compared with the control group (100%). Conclusions: The challenges of tracheal intubation in the ST position, aimed at reducing the risk of pulmonary aspiration, can be mitigated by using a video laryngoscope, despite slightly longer intubation times.

Hip to Neck Circumference Ratio as an Independent Predictor of Difficult Intubation in Obese Patients

Background: Anaesthesiologists face difficult intubation (DI) more frequently in obese patients. Thus, we aimed to test if central obesity indices including hip circumference (HC), neck circumference (NC) or waist circumference (WC) can effectively predict DI and difficult mask ventilation (DMV) in them. Methods: HC, NC, WC, mask ventilation grade, intubation difficulty scale (IDS), history of snoring and obstructive sleep apnoea (OSA) were measured in 300 patients with BMI ≥ 30 kg/m2. Receiver operating characteristic curve (ROC) and multivariate, logistic regression were employed to identify predictors of DI (IDS ≥5) and DMV define as mask ventilation grade of 3 or 4. Results: DI and DMV were, respectively, detected in 14.7% and 12.7% of subjects. According to Multiple logistic regression analysis BMI (Odds ratio (OR):1.17, 95% confidence interval (CI): 1.08-1.28, p<0.001), NC (OR: 1.26, 95% CI: 1.04-1.52, p=0.01), HC (OR:1.06, 95% CI: 1.03-1.10) and HC/NC ratio (OR: 4.9, 95% CI: 1.64-14.92, p= 0.004) considered as independent predictors of DI. The same analysis recognized BMI (OR:1.13, 95% CI: 1.03-1.24, p=0.006), WC (OR: 1.06, 95% CI:1.01-1.11, p=0.01), and HC/BMI ratio (OR=0.18, 95% CI:0.06-0.53, p=0.002) as DMV predictors. Sensitivity of BMI >35.8 kg/m2, NC >39.9 centimetres (cm), HC>118cm and HC/NC ratio >2.9 were determined as 70.5%, 68.2%, and 69.3% respectively for prediction of DI. Sensitivity of BMI >36.6 kg/m2 and WC >118 cm for predicting DMV were identified as 71.0% and 73.6%. Conclusion: This study proposes to simultaneously consider the HC/NC ratio and WC as a predictor of difficult airway in the obese.

Comparison of king vision video laryngoscope with macintosh laryngoscope for nasotracheal intubation: Randomized control study

Nasotracheal intubation is essential in oro-maxillofacial surgeries to provide a good operational field along with a secured airway. In this study, we aim to compare king vision video laryngoscope with conventional Macintosh laryngoscope for nasotracheal intubation in ear, nose throat and oro-maxillofacial surgeries under general anaesthesia. A total of 102 patients were posted for elective oro-maxillofacial surgeries under general anaesthesia with nasal intubation. Patients were randomized to two different groups. In group K nasotracheal intubation was done with king vision video laryngoscope (KVVL) and in group M with Macintosh laryngoscope. Primary objective was to compare total intubation time and each time intervals (time A: placement of the nasal tube from selected nostril to oropharynx; time B: use of devices to view the glottis, and time C: for nasal tube to be advanced from oropharynx into trachea and removal of the laryngoscope from oral cavity). Secondary objectives were to compare scores of Modified Naso Intubation Difficulty Scale (MNIDS) and haemodynamic responses.The mean total intubation time, and time C interval were noted in King Vision Video Laryngoscope group (37.29±7.83 s and 15.99±8.9 s) and Macintosh laryngoscope group (46.11±10.05 s and 19.86±9.96 s) respectively. There was significant difference between these two groups in terms of mean total intubation time, and time C interval (total time, p=0.001 and time C, p=0.041). The level of difficulty in intubation noted using MNIDS score which is zero in 52.9% patients in King Vision group and 23.5% in Macintosh group (p=0.011).As compared to Macintosh laryngoscope, the king vision laryngoscope requires lesser time for nasotracheal intubation. In addition, Intubation is easier with the king vision laryngoscope than with the Macintosh laryngoscope.

A prospective randomized comparative trial of pediatric C-MAC D-blade video laryngoscope with McCoy direct laryngoscope for intubation in children posted for elective surgical procedures under general anesthesia.

Pediatric airway management requires careful clinical evaluation and experienced execution due to anatomical, physiological, and developmental considerations. Video laryngoscopy in pediatric airways is a developing area of research, with recent data suggesting that video laryngoscopes are better than standard Macintosh blades. Specifically, there is a paucity of literature on the advantages of the C-MAC D-blade compared to the McCoy direct laryngoscope. After Ethics Committee approval, 70 American Society of Anesthesiologists physical status 1 and 2 children aged 4-12 years scheduled for elective surgery under general anesthesia were recruited. Patients were randomly allocated to intubation using a C-MAC video laryngoscope size 2 D-blade (Group 1) and a McCoy laryngoscope size 2 blade (Group 2). The Intubation Difficulty Scale (IDS) for ease of intubation was the primary outcome, while Cormack-Lehane grades, duration of laryngoscopy and intubation, hemodynamic responses, and incidence of any airway complications were secondary outcomes. Both groups were comparable in terms of patient characteristics. The median (IQR) Intubation Difficulty Scale (IDS) score was better but was statistically nonsignificant with C-MAC (0 [0-0] vs. 0 [0-2], p = .055). The glottic views were superior (CL grade I in 32/35 vs. 23/35, p = .002), and the time to best glottic view (6 s [5-7] vs. 8.0 s [6-10], p = .006) was lesser in the C-MAC D-blade group while the total duration of intubation was comparable (20 s [16-22] vs. 18 s [15-22], p = .374). All the patients could be successfully intubated on the first attempt. None of the patients had any complications. The C-MAC video laryngoscope size 2 D-blade provided faster and better glottic visualization but similar intubation difficulty compared to McCoy size 2 laryngoscope in children. The shorter time to achieve glottic view demonstrated with the C-MAC failed to translate into a shorter total duration of intubation when compared to the McCoy laryngoscope attributable to a pronounced curvature of the D-blade.

Comparison of Efficacy of Intubation with HugeMed Non-channelled Video Laryngoscope, McCoy and Macintosh Laryngoscope in Simulated Difficult Laryngoscopy Using Rigid Cervical Collar: A Prospective Randomized Trial.

In cervical spine injuries, there is an impairment in positioning of the patient to maintain the airway axis during endotracheal intubation (ETI). Literature shows video laryngoscope (VLS) facilitating the intubation in these patients with cervical immobilization. VL3 VLS (HugeMed Medical Technical Development, Shenzhen, China) is a newer VLS with limited studies. The primary aim of this study is to compare the efficacy of ETI using VL3 VLS with Macintosh and McCoy (MC) blades for simulated difficult airway with rigid cervical collar (RCC). The secondary aim was to compare the oral insertion of laryngoscope and intraoral bleeding. One hundred and fifty patients were randomly divided into three groups depending on laryngoscope used for ETI. Group M, Group V, and Group MC used Macintosh, VL3, and MC laryngoscopic blades, respectively, for ETI. During ETI, the Intubation Difficulty Scale (IDS), intubation time (IT), ease of laryngoscope insertion, and any bleeding intraorally were noted. The data collected were further analyzed. IDS was statistically significantly least (0.9 ± 1.5) with VL3 VLS compared to direct laryngoscopy with Macintosh and MC blades. There was significantly no difference in IT among the three groups. Insertion of blade of VL3 was significantly more difficult than Macintosh or MC. Intraoral bleeding was present in 8% of patients with VL3. VL3 VLS can be used for ETI during cervical immobilization using RCC. More studies are needed to define its efficacy in different difficult airway situations compared with different VLS.

Ultrasound-based assessment of tongue thickness for prediction of difficult laryngoscopy and intubation.

Predicting difficult airway and preparedness for the same can help prevent catastrophic situations while handling the airway. With the increasing familiarity of anaesthesiologists to the use of ultrasound machine and its easy availability and non-invasiveness, we sought to study its utility in airway assessment, by measuring the thickness of tongue, to predict difficult laryngoscopy and intubation. A total of 85 patients undergoing elective surgeries under general anaesthesia with endotracheal intubation were examined preoperatively. Tongue thickness was measured using submental ultrasonography in the median sagittal plane along with other tests of airway assessment. Cormack Lehane grade on laryngoscopy and Intubation Difficulty Scale Score was recorded. The sensitivity, specificity, positive and negative predictive value, and accuracy was calculated for tongue thickness for predicting difficult intubation. The tongue thickness in those with difficult intubation (4.83 ± 0.62) was significantly higher than those without difficult intubation (4.38 ± 0.65). The ratio of tongue thickness to thyromental distance was also significantly higher in difficult intubation group. The area under the receiver operating characteristic curve for predicting difficult laryngoscopy and intubation was higher for tongue thickness as compared to other clinical parameters. The sensitivity and specificity of tongue thickness to predict difficult laryngoscopy was 100% and 83%, respectively, and to predict difficult intubation was 72% and 59%, respectively, with an accuracy of 72%. Ultrasound based assessment of tongue thickness can be a useful predictor of difficult airway along with clinical assessment of the airway.

SNIFFING VERSUS RAMPED POSITION IN THE VIDEO-LARYNGOSCOPY-GUIDED TRACHEAL INTUBATION OF MORBIDLY OBESE PATIENTS: A PROSPECTIVE RANDOMIZED OBSERVATIONAL STUDY

Sniffing versus Ramped position in the videolaryngoscopy-guided tracheal intubation of morbidly obese patients: a prospective randomized observational study” Introduction: Ramped positioning is recommended for intubating obese patients undergoing direct laryngoscopy. However, whether the use of the ramped position can provide any benefit in videolaryngoscopy-guided intubation remains unclear. This study assessed intubation time using videolaryngoscopy in morbidly obese patients in the ramped versus sniffing positions. Materials and Methods: This is a prospective randomized observational study in patients with morbid obesity (n = 82 body mass index [BMI] ? 35 kg/m2). Patients were randomly allocated to either the ramped or the standard sniffing position groups. During the induction of general anesthesia, difficulty in mask ventilation was assessed using the Warters scale. Tracheal intubation was performed using a C-MAC® D-Blade videolaryngoscope, and intubation difficulty was assessed using the intubation difficulty scale (IDS). The primary endpoint was the total intubation time calculated as the sum of the laryngoscopy and tube insertion times. Conclusion: Compared with the sniffing position, the ramped position reduced intubation time in morbidly obese patients and effectively facilitated both mask.

Relationship Between Airway Examination with LEMON Criteria and Difficulty of Tracheal Intubation with IDS Criteria.

Tracheal intubation is a common technique used to secure a patient's airway, which is crucial in anesthesia. Successful tracheal intubation depends on various factors, including the assessment of the patient's airway before the procedure. In recent years, scoring systems, such as LEMON (an acronym for the assessment of the airway's appearance, identification of any dental issues, evaluation of Mallampati classification, assessment of airway obstruction, and examination of neck mobility) and intubation difficulty scale (IDS) have gained attention. This study aimed to investigate the relationship between the LEMON criteria and IDS in tracheal intubation. The goal was to provide valuable insights that can assist medical professionals in optimizing their approach to airway management by analyzing clinical data, assessing patient outcomes, and evaluating the consistency between these scoring systems. This study was based on a descriptive-analytical study involving a group of patients requiring intubation. This study examined 105 patients scheduled for elective surgeries, aged between 19 and 60 years, without specific underlying diseases, such as laryngeal cancer, temporomandibular joint stiffness, or significant tongue enlargement, and with a body mass index (BMI) below 40 kg/m². Initially, expert anesthesiologists assessed the patients using the LEMON criteria, and then the degree of intubation difficulty was measured using the IDS scoring system. Finally, these two criteria were compared. In this study, there was a significant correlation between the LEMON score and the IDS score (P < 0.001). The difficult intubation group (IDS score higher than 0) had higher LEMON scores (with the highest score equal to 4) than the non-difficult intubation group (IDS score of 0) (P = 0.017). The average LEMON and IDS scores were 3.11 and 1.35, respectively. Among the participants, 96.2% had an intubation difficulty score of ≤ 5; nevertheless, 3.8% had a score of > 5. Additionally, limited neck mobility emerged as the sole independent predictor of intubation difficulty (P = 0.002, odds ratio = 6.152). The LEMON score is associated with difficult intubation in adult patients requiring intubation.

MONTH Score in Predicting Difficult Intubations in Emergency Department; a Prognostic Accuracy Study.

MONTH Difficult Laryngoscopy Score was developed for effectively identifying difficult intubations in the emergency department (ED). This study aimed to evaluate the accuracy of MONTH Score in predicting difficult intubations in ED. We prospectively collected data on all patients undergoing intubation in the ED of Ramathibodi Hospital, Bangkok, Thailand. The screening performance characteristics of the MONTH score in identifying the difficult intubation in ED were analyzed. All data were analyzed using STATA software version 18.0. 324 intubated patients with the median age of 73 (63-82) years were studied (63.58% male). The proportion of difficult intubations was 19.44%. The sensitivity and specificity of MONTH in predicting difficult intubations were 74.6% (95% CI: 61.6%-85.0%) and 92.8% (95% CI: 89.0%-95.6%), respectively. These measures in subgroup of patients with Intubation Difficulty Scale (IDS) score ≥ 6 were 44.1% (95%CI: 31.2-57.6) and 98.5% (95% CI: 96.2%- 99.6%), respectively. The area under the receiver operation characteristic (ROC) curve of MONTH in predicting difficult intubations was 0.895 (95% CI: 0.856- 0.926). It seems that the MONTH Difficult Laryngoscopy Score could be considered as a tool with high specificity and positive predictive values in identifying cases with difficult intubations in ED.

COMPARISON OF TOTAL AIRWAY SCORES AND INTUBATION DIFFICULTY SCORES IN DENTAL PROCEDURES PERFORMED UNDER GENERAL ANESTHESIA: A RETROSPECTIVE STUDY

The Total Airway Score, determined by eight bedside tests during the preoperative period, and the Intubation Difficulty Scale, assigned during intubation, are both used to describe and predict difficult intubation. The aim of this study is to investigate the correlation between the Total Airway Score and the Intubation Difficulty Scale.Two hundred,American Society of Anesthesiologists ASA 1-3 patients elective dental treatment, maxillofacial surgery under general anesthesia were included in the study. Airway evaluation was performed preoperatively by total airway score which were; Mallampati classification, thyromental and sternomental distance measurement, head and neck mobility,body mass index (BMI), presence of buck teeth, inter incisors gap, upper lip bite test. After endotracheal intubation, the patients were divided into two groups as a healthy group (intubation difficulty scale (IDS)&amp;lt;4) and difficult intubation (IDS ≥4) according to their estimated difficult intubation scores with seven variables and compared with patients with total airway score &amp;gt; 3 in two groups. In this study, total airway score (&amp;gt; 3), thyromental distance (&amp;lt;6cm), upper lip bite test (class III), mallampati classification (≥ class III), inter incisors gap (&amp;lt;3 cm) and buck teeth (&amp;gt; 0.5) respectively 49.45 (95% CI = 4.75-515.45, P &amp;lt;0.05) 7.72 (95% CI = 1.81-32.9, P &amp;lt;0.05), 21.12 (95% CI = 2.31-192.27, P &amp;lt;0.05), 1.92 (CI 95% = 0.51-7.22), 3.54 (95% CI-) 2.31 (95% CI = 0.49-10.78) was detected.It is concluded that total airway score (&amp;gt; 3), upper lip bite test (class III),thyromental distance measurement (&amp;lt;6 cm), which we use in predicting difficult intubation are the most useful preoperative evaluation factors.

Prediction of difficult laryngoscopy and/or intubation among morbidly obese patients: Upper lip bite test versus modified Mallampati classification.

We aim to compare the upper lip bite test with the modified Mallampati test as predictors of difficult laryngoscopy and/or difficult intubation among morbidly obese patients. A total of 500 morbidly obese patients (body mass index > 40 kg/m2) undergoing general anaesthesia with tracheal intubation are included in this prospective single-blinded observational clinical study. The preoperative airway assessment is obtained by the modified Mallampati test and upper lip bite test. The difficulty of laryngoscopy is assessed by an experienced anaesthetist in patients adequately anaesthetised and fully relaxed. The view is classified according to Cormack and Lehane's classification. Modified Mallampati test III or IV and upper lip bite test III are considered positive tests. Difficult laryngoscopy is defined as Cormack and Lehane's classification III and IV, whereas difficult endotracheal intubation is defined as an intubation difficulty scale ⩾ 5. The incidences of Cormack and Lehane's classification III and IV and intubation difficulty scale ⩾ 5 are 9.4% and 11.8% respectively. The specificity, positive predictive value and accuracy are higher with the upper lip bite test. The combination of the upper lip bite test and the modified Mallampati test improved these measures. The likelihood ratio + was significantly higher for the upper lip bite test (6.35 and 9.47) than for the modified Mallampati test (3.21 and 3.16). The upper lip bite test is a test with high sensitivity, specificity, negative predictive value and accuracy making it a favourable test for identifying easy and difficult intubations and laryngoscopies in morbidly obese patients.

Can chin-nape circumference and the ratio of neck circumference to chin-nape circumference predict difficult mask ventilation or difficult intubation in obese patients?

We aimed to evaluate the success of the ratio of chin-nape circumference (CNC) and neck circumference (NC) to CNC in predicting difficult mask ventilation (DMV) or difficult intubation (DI). Eighty-seven obese patients (body mass index ≥ 30) were evaluated between September 15, 2019 and September 15, 2020. Mallampati score, mouth opening, upper lip bite test, distance between incisors, thyromental distance (TMD), sternomental distance (SMD), and thyromental height were recorded. NC and CNC were measured in a neutral position. The ratio of NC to TMD and the ratio of NC to CNC were calculated. Mask ventilation was graded according to the method described by Han et al (Grade 3 or 4 equals DMV). DI assessment was performed using the intubation difficulty scale (IDS, IDS < 5 equals easy intubation, IDS ≥ 5 equals DI). Logistic regression analysis was performed to identify the variables thought to be effective in DMV and DI. Receiver operating characteristic curves were generated for each parameter considered effective. DMV was found in 17.2% (n = 15) of the patients included in the study, and DI was found in 16.1% (n = 14). The relationship between DMV and age, male gender, obstructive sleep apnea syndrome, NC, ratio of NC to TMD, ratio of NC to SMD, ratio of NC to CNC, and CNC was significant. Male gender and NC >45.5 cm were independent risk factors for DMV. The relationship between DI and distance between incisors, NC, ratio of NC to TMD, ratio of NC to SMD, and CNC was significant. A distance between the incisors < 4.85 cm and a NC > 41.5 cm were found to be independent risk factors for DI. CNC may predict DMV and DI in obese patients. The ratio of NC to CNC may predict DMV in obese patients.

Comparison of intubating conditions in supine (sniffing) and 25° back-up position using channelled and non-channelled video laryngoscopes - A randomised controlled study.

The 25°back-up position is proposed to increase the efficacy of preoxygenation and provide better tracheal intubating conditions when using a direct laryngoscope. This study aimed to compare the ease of tracheal intubation between supine and 25° back-up positions when using two video laryngoscopes (VLS). One hundred adults with normal airways and belonging to the American Society of Anesthesiologists physical status classes I and II, requiring general anaesthesia, were randomised in groups K and M. The trachea was intubated using King Vision and McGrath VLS in either supine (groups K1 and M1) or 25° back-up (groups K2 and M2) positions. The 25° backup position was given by raising the operating table from the horizontal position by flexing the torso at the hips so that an imaginary line connected the patient's external auditory meatus to the sternal notch. Modified Intubation Difficulty Scale (mIDS) was the primary outcome, and intubation time, the number of intubation attempts, vital parameters, and complications were compared secondarily. Statistical analysis was done using MedCalc software by applying an independent t-test for parametric data and a Chi-square test for categorical data and finding the risk ratio. Mean (Standard deviation) mIDS was significantly reduced using both VLS in the 25° back-up position [0.92 (0.75) versus 0.48 (0.58), P = 0.025, degree of freedom (DF): 48, mean difference (95% confidence interval [CI]):-0.44 (-0.821 to - 0.059) in group K1 versus group K2 and 0.76 (0.59) versus 0.36 (0.48), P = 0.012, DF: 48, mean difference (95% CI): -0.40(-0.706 to - 0.094) in group M1 versus group M2, respectively]. The risk ratio comparing both the positions for the total number of patients requiring manoeuvres during intubation using both the VLS was 0.48 with P = 0.0004 and 95% CI = 0.305 - 0.765. Intubation time was shorter in the 25° backup position by using King Vision (P = 0.005) and McGrath (P = 0.042) VLS. The 25° backup position helps provide ease of intubation using both the channelled (King Vision) and non-channelled (McGrath) VLS.

Evaluation and comparison of sonographic difficult airway assessment parameters with clinical airway predictors.

None of the clinical difficult airway predictors are 100% sensitive and specific. Ultrasound is being used for airway assessment, but there is still no established parameters or model to predict difficult laryngoscopy. This observational study was planned to determine the predictive ability of clinical and sonography-based airway assessment parameters for difficult laryngoscopy and intubation. A total of 130 patients of 18-60 years of age undergoing elective intubation were included. The distribution of Cormack-Lehane (CL) grade and intubation difficulty scale (IDS) was correlated with the clinical and sonographic screening parameters for difficult airways. The prevalence of difficult laryngoscopy and difficult intubation in our study was 17.6% and 11.5%, respectively. Mallampati grade (MMG), upper lip bite test (ULBT), neck circumference, hyomental distance ratio (HMDR), tongue thickness (TT), skin to epiglottis/epiglottis to vocal cord distance (SED/E-VC), and mandibular condylar mobility (MCM) had significant association with the difficult laryngoscopy and MMG, neck circumference, SED, SED/E-VC; MCM had significant association with the difficult intubation. The combination of these predictors showed better diagnostic ability for difficult airways. Model 1 based on ultrasound parameters showed an area under the curve (AUC) of 0.848 (CI- 0.748-0.947, P value < 0.0001) and model 2 based on combined clinical and ultrasound parameters showed an AUC of 0.755 (95% CI- 0.631-0.879, P value < 0.0001). Ultrasound-based airway predictors can help in predicting difficult laryngoscopy and intubation along with the clinical parameters. Individual sonographic predictors have moderately satisfactory diagnostic profiles. The models based on combined tests have better diagnostic value.

Medcaptain® video laryngoscope improves nasotracheal intubation in maxillofacial surgery: A randomized clinical trial

BackgroundNasotracheal intubation may be required to secure the airway in oral and maxillofacial surgery. AimTo evaluate the effectiveness of the video laryngoscope compared with the Macintosh laryngoscope for nasotracheal intubation in maxillofacial surgery. MethodsThis prospective, randomized, single-blind trial compared the video laryngoscope with the Macintosh laryngoscope for nasotracheal intubation in the adult population.The patients were randomized into two groups: Group M, which underwent intubation with a Macintosh laryngoscope; and Group V, which underwent intubation with a video laryngoscope (Medcaptain®), using an adapted blade (no. 3 for women and no. 4 for men). The modified nasotracheal intubation difficulty scale (NIDS), the three-step evaluation of nasotracheal intubation, the Cormack–Lehane score, the percentage of glottic opening (POGO) scale, and complications were compared. ResultsIn total, 62 patients (31 in each group) were included in the study. The total intubation duration, oropharynx–glottis time, and glottis–trachea time were significantly lower in Group V compared with Group M (p = 0.001, p = 0.007, and p = 0.008, respectively). Group V also had a significantly lower NIDS score (p = 0.001), a higher POGO score (p = 0.002), and a lower Cormack–Lehane score (p = 0.034) compared with Group M. The use of Magill forceps was less frequent in Group V (p = 0.002). The two groups showed comparable results for nose–oropharynx time, epistaxis, and hoarseness (p = 0.068, p = 0.43, and p = 0.74, respectively). ConclusionVideo laryngoscopy appears to provide easier and faster nasotracheal intubation in maxillofacial surgery. Clinical trial registrationThis study was registered in the Pan African Clinical Trials Registry (PACTR) under the reference PACTR202303563303199.

Left Head Rotation as Alternative to Difficult Tracheal Intubation: Randomized Open Label Clinical Trial.

Tracheal intubation is a life-saving intervention not only for physicians but also for allied health workers. Optimizing the patient's head and neck position for the best glottic view is a crucial step that accelerates tracheal intubation. The left head rotation maneuver has been recently described as an innovative approach to tracheal intubation with marked improvement in glottic visualization and can be an alternative before proceeding to a surgical airway. This study compared the glottic view and intubating conditions in the sniffing position versus left head rotation during direct laryngoscopy. This randomized, open-label clinical trial enrolled fifty-two adult patients admitted to the Baguio General Hospital & Medical Center from September 2020 to January 2021 for an elective surgical procedure requiring tracheal intubation under general anesthesia. Intubation was done using a 45-degree left head rotation in the experimental group (n=26), while the control group (n=26) was intubated using the conventional sniffing position. Glottic visualization and intubation difficulty with left head rotation and sniffing position were assessed using Cormack-Lehane Grade and Intubation Difficulty Scale, respectively. Successful intubation is measured by observing a capnographic waveform in the end-tidal CO2 monitor after placement of the endotracheal tube. There was no significant statistical difference in the clinicodemographic characteristics between the left head rotation and sniffing position groups. There was no statistically significant difference in the Cormack-Lehane Grade, with 85% of patients classified under Grades 1 and 2 in both groups. Also, there were no statistically significant differences in the Intubation Difficulty Scale scores of patients intubated with left head rotation or sniffing position; 30.7% of patients in both groups were easily intubated, while 53.8% in left head rotation and 57.6% in sniffing position groups were intubated with slight difficulty. Similarly, there were no significant differences between the two techniques in any of the seven parameters of the Intubation Difficulty Scale, although numerically fewer patients required the application of additional lifting force [7 (26.9%) vs. 11 (42.3%)] or laryngeal pressure [3 (11.5%) vs. 7 (26.9%)] when intubated with left head rotation. The intubation success rate with left head rotation was 92.3% vs. 100% in the sniffing position, but this difference was not statistically significant. Left head rotation produces comparable laryngeal exposure and intubation ease to the conventional sniffing position. Therefore, left head rotation may be an alternative for patients who cannot be intubated in the sniffing position, especially in hospitals where advanced techniques such as video laryngoscopes and flexible bronchoscopes are unavailable, as is the case in this study. However, since our sample size was small, studies with a larger study population are warranted to establish the generalizability of our findings. In addition, we observed inadequate familiarity among anesthesiologists with the left head rotation technique, and the intubation success rate may improve as practitioners attain greater technical familiarization. This trial was registered in the International Traditional Medicine Clinical Trial Registry (ISRCTN23442026).

Thyomental distance is a good difficult airway indicator: Truth or a misconception- A prospective observational study

Unanticipated difficult intubation can be a true challenge to any anaesthesiologist. The most widely used determinant till date in almost every airway study is Thyromental distance[TMD]. We aimed to determine if a TMD above the average values could indicate difficult intubation.70 patients were selected in this prospective observational study who require general anesthesia with endotracheal intubation for their respective surgeries. Patients who fulfilled the inclusion criteria were enrolled in the study and informed written consent was taken.Routine pre-anesthetic check up was done. Thyromental distance was measured [thyroid notch to the lower border of the mandibular mentum-head fully extended] using a rigid ruler. Intraoperatively: After following standard general anaesthesia protocol, patients were intubated by anesthesiologist with atleast 2 years of experience and blinded to the study. The ease (0-5) / Difficulty (&amp;#62;5) in intubation was assessed with Intubation difficulty scale(IDS). Data was analysed using SPSS Software 16. Data was expressed in terms of frequency and percentage. In a total of 70 patients, 18.6% of the patients had difficult intubation. It was observed that 50 patients had a TMD &amp;#62;=7.5 cm out of whom, 7 patients were difficult to intubate. 12 patients had TMD&amp;#60;6.5 cm out of which 6 patients had an IDS of &amp;#62;5 indicating difficult intubation. Sensitivity, specificity, PPV, NPV were calculated. Categorical Pearson chi square test was done for TMD&amp;#62;7.5 vs IDS and it showed a p value of 0.017 (p&amp;#60;0.05).We observed that a long TMD (TMD&amp;#62;=7.5cm) could be a difficult airway indicator just like a short TMD (TMD&amp;#60;=6.5). Therefore, our findings suggest that thyromental distance may not have a significant role as a standalone pre-operative indicator of a difficult airway and its reliability as a useful parameter in predicting difficult intubation is questionable.

Prognostic value of the intubation difficulty scale in bariatric surgery

The objective was to assess the predictive value of the risk scale for difficult intubation in obese patients. Materials and methods. The object of the study was 110 patients (90 women and 20 men) operated on as planned in 2022. The mean age of the patients was 42 ± 11 years. The median body mass index (BMI) was 43.7 kg/m 2 (Q1–Q3: 37.9–49.1). All patients underwent a standard preoperative examination with the identification of the risk of difficult airways according to the intubation difficulty scale (IDS): mouth opening, neck mobility, mandibular protrusion, Mallampati class, sternomental and thyromental distances, and history of previous intubations were assessed. Results. Difficult intubation (3–4 degrees according to Cormack–Lehane) were detected in 19 patients (17.3 %). ROC-analysis revealed the dependence of the probability of difficult intubation on the total points on the intubation difficulty scale. The area under the ROC curve was 0.809 ± 0.063 with 95 % CI: 0.685 – 0.932. The model was statistically significant (p &lt; 0.001). The cut-off point value for the total points on the intubation difficulty scale, which corresponded to the highest value of the Youden index, was 4. The sensitivity and specificity of the model were 100.0 % and 47.3 %, respectively. Significant differences (p &lt; 0.001) were found in the analysis of the risk of difficult intubation depending on the total points on the intubation difficulty scale. The most significant differences (p &lt; 0.001) were demonstrated by the mouth opening width and neck mobility. There were no differences (p = 0.547) when analyzing the history of difficult airways and nighttime snoring. Conclusion. Overall, the intubation difficulty scale showed predictive value in terms of assessing the risk of difficult airways (p = 0.002, χ2 = 13.230). The most reliable indicators for predicting the risks of difficult intubation were mouth opening less than 4 cm (p &lt; 0.001, χ2 = 11.185) and head and neck flexion in the atlanto-occipital joint less than 90о (p &lt; 0.001, χ2 = 10.858). Assessment of thyromental and sternomental distances, mandibular protrusion ability, and Mallampati class also showed statistical significance. Prior history of difficult intubation and nighttime snoring showed no statistically significant risk in predicting difficult airways (p = 0.547, χ2 = 0.363).

Intubation of Critically Ill COVID-19 Patients Using Conventional Laryngoscope in the ICU

Background: Video laryngoscopy is recommended for critically ill COVID-19 patients due to safety concerns and avoid complications. It is not available in some places and thereby forcing the operator to rely on conventional laryngoscope. Intubations in critically ill COVID-19 patients are challenging and may lead to adverse complications which may be affected by the laryngoscope used. The aim of the study was to analyse predictors of difficult intubation, complexity of intubation and complications of using conventional laryngoscopy in intubations of COVID-19 patients in ICU. Methods: A prospective observational study was done in COVID Intensive Care Unit of the Base Hospital- Teldeniya, Sri Lanka from 1st of January 2021 to August 2021. The data was collected using a Performa filled by operator at the end of the intubation. Apart from demographic data and clinical parameters, data related to intubation including MACOCHA score which is a validated score predicting difficult intubation in ICU(3) and Intubation difficulty scale (IDS) which measures the actual complexity of intubation(4) were collected. The complications related to intubation were also analysed. Results: Approximately 84 out of 91 emergency intubations were done using conventional laryngoscope. Out of them 50.72 % were male and 49.27% Were female. Mean age was 50.75 years. First pass success rate was 83.3%. 25% had MACOCHA score more than 3. Most patients scored on the desaturation component of the score. Despite this only 50% of the predicted difficult intubations actually had major difficulty in intubation. The commonest complication was hypotension. 12 had suffered cardiac arrest, and 4 of them were fatal. Conclusions: Intubation of Critically ill COVID-19 patients are challenging but can be done successfully with conventional laryngoscope. However, one must prepare for complications including cardiac arrest.