Incidence Of Failed Intubation Research Articles

Comparison of Airtraq™ video-laryngoscope and Macintosh laryngoscope for tracheal intubation in adults—a randomised study

BackgroundAirway management by intubation is considered a major responsibility and vital skill for anaesthesiologists. Direct laryngoscopy and endotracheal intubation under vision continues to be the gold standard for airway management. Though conventional laryngoscopy is done with Macintosh blade, it has its own drawbacks. The Airtraq™ is a tube/guide channelled video-laryngoscope and can be used in patients with normal as well as difficult airway. On literature review, studies comparing intubation time with Airtraq™ and Macintosh laryngoscopes have shown heterogeneous results. Therefore, the present study was designed to compare the Airtraq™ video-laryngoscope and Macintosh laryngoscope for tracheal intubation in adults.ResultsThe median time to intubation was significantly longer in group A [45 (27–77) s] than in group M [24 (21–26) s] (p < 0.001). In both groups, 96% patients had POGO score 75–100% and CL grade I. Intubation was noted to be easy in 88% cases in group A and 92% in group M (p > 0.05). Three cases in group A required a second attempt for successful intubation, whereas in group M, all cases were intubated in the first attempt (p > 0.05). Hemodynamic parameters and complications were comparable among the groups (p > 0.05).ConclusionsAirtraq™ video-laryngoscope took longer time for intubation than Macintosh laryngoscope. However, both the devices were similar in terms of glottic view, ease of intubation, number of intubation attempts, incidence of failed intubation, hemodynamic changes, and complications. The overall performance of Airtraq™ video-laryngoscope was similar to Macintosh laryngoscope in patients having normal airways.

Comparison of face-to-face tracheal intubation and conventional head-end tracheal intubation using Airtraq™ video-laryngoscope in adults - A randomised study.

Tracheal intubation can be difficult in certain scenarios where the head-end of the patient is not accessible as in entrapped casualties. A face-to-face technique using a video-laryngoscope can prove to be useful in such scenarios. However, the two positions of tracheal intubation namely, face-to-face and head-end, using video-laryngoscope have never been compared in patients. Fifty patients of either sex, between 18 and 60 years, ASA class I/II, MPC I/II, scheduled to undergo surgical operations requiring general anesthesia with tracheal intubation were randomly allocated to either Group F (face-to-face intubation) or Group H (head-end intubation). Intubation was performed using Airtraq™ video-laryngoscope in both groups. Time taken for successful intubation, device insertion time, glottic view as per Cormack and Lehane (CL) grade, ease, attempts, the incidence of failed intubation, and hemodynamic parameters were noted. The time taken for successful intubation in Group F was significantly longer than in Group H (38.09 ± 19.45 s vs. 19.32 ± 9.86 s, respectively; P < 0.001). Three cases of failed intubation were noted in Group F compared to none in Group H (P = 0.235). Glottic view, ease, attempts, and hemodynamic parameters were comparable among the groups (P > 0.05). The time taken for successful tracheal intubation was longer in face-to-face technique than in head-end technique in patients with the normal airway. However, both techniques were similar in terms of glottic view, ease of intubation and number of intubation attempts, the incidence of failed intubation, and hemodynamic changes. Therefore, face-to-face tracheal intubation is a good alternative to secure the airway when the head-end is not accessible.

Comparison of Mc Grath-MAC and C-MAC video laryngoscopes for intubation in a COVID simulated mannequin by novice users wearing face protective gear: A randomized crossover trial

Introduction:Intubation in COVID patients is challenging. Various guidelines suggest the use of video-laryngoscope (VL) as the first device to aid intubation in a COVID patient. The best VL to facilitate intubation in such a setting especially by novices is not ascertained. We compared intubation characteristics by two VL's (McGrath-MAC and C-MAC) for intubation in a COVID simulated mannequin by novices.Methodology:This prospective randomized manikin-based crossover study was done in thirty medical professionals with no previous experience of intubation with VL. All participants were trained on Laerdel airway management trainer and were allowed 5 practice sessions with each scope with an intubation box while wearing face protective personal protective equipment (PPE). Participants were randomized into two groups of 15 each, one group performed the intubation first with McGrath and the other with C-MAC before crossing over.Results:The mean (S. D.) time to intubation was similar with both McGrath-VL and CMAC VL [31.33 (14.72) s vs 26.47 (8.5) s, P = (p-0.063)]. POGO score [mean (S. D.)] was better with CMAC [81.33 (16.24) vs 60.33 (14.73), p-0.00. The majority of the users preferred C-MAC VL for intubation (93.33%). The incidence of failed intubation and multiple attempts at intubating were similar with the two scopes.Conclusion:The time to intubation was similar with both VL's but the majority of novices preferred CMAC probably due to a bigger screen that helped them to have a better view of glottis in the COVID simulated mannequin.

Airway management at Level 1 trauma center in the era of video laryngoscopy.

Background:Rapid sequence induction and tracheal intubation through direct laryngoscopy (DL) has been the most common approach to secure the airway in trauma patients. The introduction of video laryngoscopy (VL) has changed airway management in many clinical settings. In this retrospective study, we assessed if immediate availability of VL in the trauma suite has changed the approach and outcomes of airway management during acute resuscitation at a dedicated trauma center.Materials and Methods:We retrospectively collected data from emergency intubation in the 6 resuscitation bays at a high-volume, academic, Level 1 trauma center over a 42-month period following the introduction of immediately available VL in the resuscitation bay. We divided the data into 13-week bins to assess the trend in the use of VL over time. Our measured outcomes were the incidence of failed intubations requiring a surgical airway and the frequency of VL use for airway management.Results:Among 1328 airway management events in the resuscitation bays when intubation was attempted, the failure rate resulting in the placement of a surgical airway was 0.38% (95% confidence interval [CI], 0.12% –0.88%). This was consistent with the surgical airway rate before the introduction of VL into trauma practice (0.3%). VL use (primary or as a rescue technique) throughout the study period was 4.14% (95% CI, 2.76%–5.74%), with no temporal trend.Conclusion:The immediate availability of VL in the resuscitation bay has not changed the prevalence of its use during emergency airway management at our trauma center. DL remains a preferred primary modality for airway management by the trauma anesthesiologists working at this facility, with an acceptably low incidence of both primary failure and the need to establish a surgical airway.

Human cadavers preserved using Thiel's method for the teaching of fibreoptically‐guided intubation of the trachea: a laboratory investigation

We assessed the suitability of human cadavers preserved using Thiel's method for teaching flexible fibreoptic tracheal intubation. Thirty-one anaesthetists unacquainted with this technique received didactic teaching followed by handling of the fibrescope on the Oxford teaching box. They then carried out fibreoptic intubations in two cadavers to establish a baseline sample of their intubation skills. Thereafter, we randomly assigned the trainees to two groups to practice fibreoptic intubation either on two distinct cadavers or on two airway manikins. After 7days we re-assessed procedural skills using the same cadavers as at baseline. Intubation time was the primary outcome and secondary outcomes included the incidence of failed intubations. We also evaluated trainee satisfaction. The mean (SD) intubation time decreased from a baseline value of 74 (20)s to 35(6)s in the cadaver group and to 56 (16)s in the manikin group. The effect of 'time' was significant (p=0.002), indicating that both methods of training led to improvements. The training effect of the cadaveric method was greater than with the manikin method (p=0.0016). Thirty-four failed intubations occurred at baseline vs. eight at the end of study (RR 0.24, 95%CI 0.11-0.51, p=0.0002, NNT 9.6); six in the cadaver group and two in the manikin group (p=0.22). We conclude that human cadavers preserved using Thiel's method are potentially better for teaching flexible fibreoptic tracheal intubation compared with manikins.

Airway management for cesarean delivery performed under general anesthesia

BackgroundWith the increasing popularity of neuraxial anesthesia, there has been a decline in the use of general anesthesia for cesarean delivery. We sought to examine the incidence, outcome and characteristics associated with a failed airway in patients undergoing cesarean delivery under general anesthesia. MethodsA retrospective review of airway management in women undergoing cesarean delivery under general anesthesia over an eight-year period from 2006–2013 at an academic medical center was conducted. ResultsDuring the study period, 10 077 cesarean deliveries were performed. Neuraxial anesthesia was used in 9382 (93%) women while general anesthesia was used in 695 (7%). Emergent cesarean delivery was the most common indication for general anesthesia. Failed intubation was encountered in only three (0.4%) women, who were successfully managed with a laryngeal mask airway. The overall incidence of failed intubation was 1 in 232 (95% CI 1:83 to 1:666) and general anesthesia was continued in all cases. There were no adverse maternal or fetal outcomes directly related to failed intubation. ConclusionAdvances in adjunct airway equipment, availability of an experienced anesthesiologist and simulation-based teaching of failed airway management in obstetrics may have contributed to our improved maternal outcomes in patients undergoing cesarean delivery under general anesthesia.

The Feeding Tube- a Simple Yet Handy Aid to Intubate an Unanticipated Difficult Pediatric Airway

Pediatric intubation requires certain unique set of additional skills compared to intubating adults. The challenges of successfully intubation of a child increases as the age and size of the child decrease and are compounded when airway difficulties arise for various reasons. Often in the rural setting, such procedures may have to be carried out by health care personnel who get trained on-the-job, and in the absence of adequate technological back-up. This leads to an increased incidence of failed intubations which can have devastating complications, especially in the pediatric age group. We describe a simple technique which helped us while intubate a 40-day old infant, without any major catastrophes.

Anestesia regional: todavía una alternativa adecuada en la parturienta con obesidad mórbida

Obesity has been identified as a significant risk factor for anaesthesia related morbidity/mortality in obstetrics. Obesity compounds most of the physiological changes in pregnancy. The obese parturients are at increased risk of having either concurrent medical problems or superimposed antenatal diseases including preeclampsia and gestational diabetes. These patients need thorough preoperative assessment, meticulous preparation and preparation for difficult airway as incidence of failed intubation is many times higher in these patients. Regional anaesthesia whenever possible is the best choice in this group of patients.

Regional anaesthesia—Still a comfortable choice in morbidly obese parturient

Obesity has been identified as a significant risk factor for anaesthesia related morbidity/mortality in obstetrics. Obesity compounds most of the physiological changes in pregnancy. The obese parturients are at increased risk of having either concurrent medical problems or superimposed antenatal diseases including preeclampsia and gestational diabetes. These patients need thorough preoperative assessment, meticulous preparation and preparation for difficult airway as incidence of failed intubation is many times higher in these patients. Regional anaesthesia whenever possible is the best choice in this group of patients.

Elective cesarean section in a parturient with post burn neck contracture: An anesthetic challenge!

The incidence of failed intubation in the pregnant population is 1 in 250-300 patients, which is 8 times higher than non-pregnant patients. Regional anesthesia is the technique of choice in a parturient with recognized potentially difficult airway for cesarean section; however, it may be controversial in the presence of anticipated intraoperative hemodynamic instability. We describe anesthetic management of 23-year-old female, gravida 2, para 1 admitted in the labor ward with central placenta previa and severe post burn contracture of neck for elective cesarean delivery.

Comparative Performance of Direct and Video Laryngoscopes in Patients with Predicted Difficult Airway

Comparative Performance of Direct and Video Laryngoscopes in Patients with Predicted Difficult Airway

Is fiberoptic bronchoscope a good intubating choice in anesthetized patients with anticipated difficult intubation?

BackgroundFiberoptic bronchoscope may be a good intubating tool in anesthetized patients with predicted difficult intubation. We conducted this prospective randomized study to compare intubation using FOB and direct laryngoscopy (DL) after induction of general anesthesia.MethodsOne hundred adult patients (50 patients in DL group, and 50 patients in the FOB group) with at least one difficult intubation criteria were enrolled in the study. Both FOB and DL were attempted after induction of anesthesia and verification of mask ventilation. Incidence of failed intubation (more than two attempts), successful intubation, and total induction times were recorded. Adverse events during intubation process were documented. Postoperatively, patients fulfilled a questionnaire to assess sequale of intubation.ResultsThe overall success rate for tracheal intubation was higher in the FOB (100% Vs 86%; p < 0.05). Successful primary and secondary intubation attempts were higher in the FOB group (94% Vs 64%; p < 0.05 and 100% Vs 61%; p < 0.05, respectively). All patients who failed laryngoscopic intubation were successfully intubated using the fiberoscope. Induction and successful intubation times were longer in the laryngoscopy group (128 + 93.7 s Vs 79.9 + 27.2 s p < 0.05 and 67.5 + 88.6 s Vs 19.2 + 27 s p < 0.05, respectively). Adverse effects including tissue trauma and dental injury were greater in the DL group. Postoperative patient's dissatisfaction, sore throat, and hoarseness were statistically higher in the DL group.ConclusionWe concluded that, FOB is an effective and safe intubating tool in anesthetized patients with anticipated difficult intubation.

The obstetric airway: things are seldom as they seem

For decades, the obstetric airway struck fear in the heart of the anesthesiologist as the incidence of failed intubation in obstetrics was reported as 1:250 to 1:300, approximately ten times more frequent than in the general surgical population. In spite of our fancy airway tools, algorithms, and difficult airway workshops, a recently published experience of more than 1,000 obstetric general anesthetics (GA) suggested we had not made progress in this area: the reported incidence of failed intubation was 1:250, and difficult intubation occurred in 3.3% of cases. So, it is with some relief that one reads the article by McKeen et al. in which they report their experience with the maternal airway over a 20-yr period at a Canadian academic tertiary care hospital. In 2,633 GAs, the incidence of failed intubation was 1:1,300, similar to that of the general surgical population, and difficult intubation was encountered in 4.7%, which is at the lower end of the reported range of 1.3% to 16.3% in obstetrics. Does this study refute the widely held belief that intubation is more difficult in the obstetric patient? In other words, do the results reflect the complete picture, or are they a case of ‘‘things are seldom what they seem’’? The reasons for the apparent difficulty in managing the obstetric airway are both clear and unclear. Undoubtedly, there are anatomic and physiologic changes in pregnancy that make the airway of the term pregnant woman more likely to present a less-than-ideal view for intubation. Nevertheless, one would think we would have found solutions to manage the pregnant airway given the many alternatives to direct laryngoscopy, the development of obstetric-specific airway algorithms and associated training drills and efforts to ensure junior trainees are supervised when providing GA. It is our view that there remains more to the story than solely the anatomical and physiological changes to the maternal airway – these factors could be overcome by the use of other airway devices. Other issues, e.g., the environment in which we provide GA in obstetrics, are more dominant and more difficult to tackle. General anesthesia usually is administered for an obstetric emergency, and under these circumstances, the available anesthesia assistance is less skilled, the atmosphere is tense, the time pressure is extreme (unlike anything else we face, other than perhaps a nasty trauma case), and our proclivity is to behave differently than we normally would for anesthesia in a high-risk patient. It is our view that the situational arena is probably the greatest key to our success or failure in managing the airway. Compounding the problem is the fact that the GA rate in obstetrics is only 5% to 7% in most tertiary care academic centres. Consequently, a staff anesthesiologist may perform only five to ten GAs per year on average, resident trainees may perform even fewer, and nursing assistance, relied on by most units, may be turned to for only one GA per year. We have become so expert at providing neuraxial anesthesia that our experience in providing GA in obstetrics has diminished markedly. M. J. Douglas, MD R. L. Preston, MD Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada

Part 8: Advanced Life Support

Part 8: Advanced Life Support

Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

Difficult and failed intubation in obstetric anaesthesia: an observational study of airway management and complications associated with general anaesthesia for caesarean section

Background Recent developments in anaesthesia and patient demographics have potentially changed the practice of obstetric general anaesthesia. There are few contemporary data on Australasian practice of general anaesthesia for caesarean section, especially relating to airway management, anaesthetic techniques and complications. Methods Using a standardised case record form, a prospective observational study was conducted during 2005-06 in 13 maternity hospitals dealing with approximately 49 500 deliveries per annum. Patient demographics, airway management, anaesthetic techniques and major complications were evaluated in those given general anaesthesia. Results Data were obtained from 1095 women receiving general anaesthesia for caesarean section, 47% of which were classified as category 1 and 18% as category 4. Tracheal intubation was planned in all cases with rapid-sequence induction used in 97%. A grade 3 or 4 laryngoscopic view was obtained in 3.6 and 0.6% of cases respectively, with 3.3% considered a difficult intubation. There were four failed intubations (0.4%, 95% CI 0.01-0.9%), of which three were subsequently managed using a laryngeal mask airway. Antacid prophylaxis was used in 94% of elective cases and 64% of emergencies. Regurgitation of gastric contents was noted in eight cases (0.7%, 95% CI 0.2-1.2%), with one confirmed case of aspiration (0.1%, 95% CI 0.002-0.5%). There were no cases of serious airway-related morbidity. Conclusions General anaesthesia is most commonly used in emergency situations. Tracheal intubation after rapid-sequence induction remains the predominant approach to airway management in Australasia. The incidence of failed intubation is consistent with previous studies. Aspiration prophylaxis is not routinely used for emergency surgery.

Prediction of difficult laryngoscopy in a population of Nigerian obstetric patients.

Difficulty in the maintenance of the airway during obstetric anaesthesia is a major contributory factor in anaesthetic related morbidity and mortality. There is an eightfold increase in the incidence of failed intubation in obstetrics. This is attributable to the physiological changes in pregnancy. Eighty consecutive obstetric patients, over a one year period who required general anaesthesia for caesarian section were evaluated using five bedside tests viz: Mallampati test, Thyrometal distance, Sterno-mental distance, Horizontal length of the Mandible and Inter-incisor gap. Eight patients had difficult laryngoscopy (10%). Mallampati test had a sensitivity, specificity and positive predictive value of 87.1%, 99.6% and 70% respectively. The values obtained for the Thyro-mental distance were 62.5%, 93.1% and 50% respectively. The other tests were not able to predict intubation difficulty significantly. When all tests were combined, sensitivity, specificity and positive predictive were values 100%, 36.1% and 14.8%. The combination of Mallampati and Thyro-mental distance had values of 100%, 93.1% and 61.5%--sensitivity, specificity and positive predictive value. Mallampati can be used as the sole predictor of difficult intubation in Nigerian obstetric patients.

Airway Management: A Review and Update

In following the 'ABCs' of resuscitation, (airway, breathing, and circulation) airway management is the first priority for patients in the emergency department, for evaluation of patients by the anesthesiologist for surgery, and for patients decompensating in the critical care setting. The goal is to ventilate adequately enough to meet the patient's oxygen demands and eliminate carbon dioxide. Over the past 20 years, changes in airway management techniques have led to decreased morbidity and mortality in both the acute care and surgical setting. With difficult intubation being reported as up to 3% of airway emergencies in the emergency department1, and the incidence of failed intubation in the operating room approximately 1 to 3 per 1000 patients2, the skillful use of both traditional and alternate techniques are necessary to provide adequate care. This review covers airway anatomy, assessment of the airway, indications for intubation, techniques, and some of the pharmacological issues in airway management.

Bias in a prehospital esophageal detector device trial: lessons learned

Our goals were to determine whether selection bias occurred in a prehospital study comparing an esophageal detector device (EDD) to a disposable capnometer for detecting esophageal intubation, and to determine whether such a bias would have changed the study's conclusions about EDD effectiveness. In a study of patients requiring prehospital intubation, we determined the sensitivity, specificity and predictive values of the EDD for detecting esophageal intubation. We then compared intubation success rate in patients who were enrolled in the study (n = 129) to that in eligible patients who were excluded from it (n = 107). After finding that the incidence of failed intubation was higher in the "excluded" group, we used sensitivity and specificity parameters derived from the study population to assess whether EDD test characteristics would differ in studied vs. excluded patients. The first intubation attempt was successful in 125 of 129 study patients and 76 of 107 excluded patients (97% vs. 71%, p = 0.03), confirming the presence of selection bias. The negative predictive value of the EDD for esophageal intubation was 98% in the study cohort and would have been 77% in patients like those excluded (i.e., difficult intubation cases). The high "first attempt" intubation success rate seen in this study was due to selective exclusion of failed intubations. This selection bias led to a clinically important overestimation of the EDD's negative predictive value. Bias may substantially alter the estimations of test accuracy reported in scientific studies. To reduce the chance of unrecognized selection bias in studies of diagnostic tests, investigators must determine whether recruited subjects resemble patients in whom the test will ultimately be used.

Paravertebral Blockade for Modified Radical Mastectomy in a Pregnant Patient

Paravertebral Blockade for Modified Radical Mastectomy in a Pregnant Patient