Intubation Attempt Success Rate Research Articles

A study of BlockBuster laryngeal mask airway versus Fastrach/Intubating laryngeal mask airway as a conduit for blind oro-tracheal intubation: A prospective randomized controlled study

A Laryngeal Mask Airway (LMA) has two parts, a simple breathing tube and a mask. The mask at the laryngeal end of the tube aligns against the glottis and provides better channel of ventilation than the face mask. There have been modifications in the basic design of the LMA to incorporate gastric drainage channel and some devices are also equipped with a channel for intubation to secure airway by guiding endotracheal tube (ETT) through it. In this study we evaluated the performance of two LMA devices that can aid in rescue ventilation and are also equipped with a channel for intubation namely the BlockBuster LMA(2012) and the Fastrach/ Intubating LMA(1997) for blind oro-tracheal intubation in terms of First attempt success rate and Over-all success rate of intubation. A hundred consenting patients of age group 18-60 years and ASA status I or II, were randomly allocated into two groups Group BB (BlockBuster LMA) and Group FT (Fastrach LMA) with 50 patients each. Standard anesthesia technique was used for both groups. After insertion of airway device, cuff was inflated and ventilation was attempted (maximum 2 attempts). Once ventilation was achieved, ETT of appropriate size was inserted through LMA (maximum 2 attempts). The correct placement of ETT was confirmed by capnography. Data was collected for number of attempts of tracheal intubation, time taken for intubation and complications. First attempt success rate of intubation was more in Blockbuster LMA than Fastrach LMA. Over-all success rate of Intubation was 100% for both devices. Time taken for intubation and incidence of post-operative sore throat was less in BlockBuster LMA than Fastrach LMA(p-value<0.05). Blockbuster LMA is better conduit for oro-tracheal intubation than Fastrach LMA in terms of higher first attempt success rate, lesser time taken for intubation and lesser post-operative complications.

Video-assisted versus macintosh direct laryngoscopy for intubation of obese patients: a meta-analysis of randomized controlled trials

INTRODUCTION: We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to compare the usefulness of video-assisted (VL) approaches with the Macintosh direct laryngoscope for endotracheal intubation of obese patients. MATERIAL AND METHODS: Studies were obtained via a systematic search of SCOPUS, Medline, Web of Science, CINAHL, and the Cochrane Central databases. The polled relative risks (RRs) odds ratios (ODs) or standard mean differences (SMD) with 95% confidence intervals (CIs) were calculated with a random–effects model. Subgroup analyses were performed to evaluate the influence of VL types on the association. RESULTS: First intubation attempt success rate in VL and DL group varied and amounted to 94.7% vs 89.5% respectively (OR = 2.04; 95% CI: 1.21–3.42; p = 0.007) and overall intubation success rate was 99.0% vs 97.5% respectively (OR = 2.20; 95% CI: 0.45–10.67; p = 0.33). Intubation time which was 48.0 ± 37.7 for VL and 48.4 ± 37.5 seconds for DL (SMD = 0.14; 95% CI: –0.33–0.61; p = 0.56). Cormack-Lehane 1 or 2 grade during intubation using VL was observed in 95.9% of cases and was statistically significantly higher than in the case of direct laryngoscopy (79.6%; OR = 6.68; 95% CI: 3.32–13.42; p < 0.001). CONCLUSIONS: Our meta-analysis suggests that video-assisted intubation may be superior to conventional intubation in an obese patient population due to a higher first–attempt success rate, better glottis visibility, and a lower rate of intubation-related injuries.

Tracheal intubation practices and adverse events in trauma victims on arrival to trauma triage: A single centre prospective observational study.

Background and Aims:Trauma is one of the leading causes of global disease burden. Data on airway management in trauma patients from developing countries, particularly India is sparse. Hence, we planned a prospective observational study to assess the airway management practice patterns and associated complications.Methods:The study was conducted in trauma triage of a tertiary care hospital. Data was collected on all tracheal intubations occurring in trauma victims requiring definitive airway control, a detailed proforma including patient details, mode of injury, drugs used, intubation procedure, and complications were filled out for each patient.Results:We observed that the airway in trauma patients was primarily managed by non-anaesthesia speciality residents (426 patients); anaesthesia residents were primarily called for deferred or difficult intubations. The first attempt success rate of intubation by anaesthesia residents was significantly higher than speciality residents (P = 0.0001; 95% CI 9.02-24.66). Non-anaesthesia residents used midazolam in varying doses (3-12 mg) for intubation, whereas, rapid sequence intubation was the most common technique used by anaesthesia residents. Airway injuries were the most frequent complication observed in 32.8% of patients intubated by specialty residents compared to 5.9% of patients intubated by anaesthesia residents.Conclusion:The trauma triage is a high-volume area for frequent tracheal intubations which are manned by non-anaesthesia speciality teams. A number of factors related to the patient, staff, availability of airway equipment and unfavourable surroundings impact airway management and may explain the high incidence of airway complications, such as airway injuries in these trauma victims.

Efficacy and Safety of Video-Laryngoscopy versus Direct Laryngoscopy for Double-Lumen Endotracheal Intubation: A Systematic Review and Meta-Analysis.

The available meta-analyses have inconclusively indicated the advantages of video-laryngoscopy (VL) in different clinical situations; therefore, we conducted a systematic review and meta-analysis to determine efficacy outcomes such as successful first attempt or time to perform endotracheal intubation as well as adverse events of VL vs. direct laryngoscopes (DL) for double-lumen intubation. First intubation attempt success rate was 87.9% for VL and 84.5% for DL (OR = 1.64; 95% CI: 0.95 to 2.86; I2 = 61%; p = 0.08). Overall success rate was 99.8% for VL and 98.8% for DL, respectively (OR = 3.89; 95%CI: 0.95 to 15.93; I2 = 0; p = 0.06). Intubation time for VL was 43.4 ± 30.4 s compared to 54.0 ± 56.3 s for DL (MD = −11.87; 95%CI: −17.06 to −6.68; I2 = 99%; p < 0.001). Glottic view based on Cormack–Lehane grades 1 or 2 equaled 93.1% and 88.1% in the VL and DL groups, respectively (OR = 3.33; 95% CI: 1.18 to 9.41; I2 = 63%; p = 0.02). External laryngeal manipulation was needed in 18.4% cases of VL compared with 42.8% for DL (OR = 0.28; 95% CI: 0.20 to 0.40; I2 = 69%; p < 0.001). For double-lumen intubation, VL offers shorter intubation time, better glottic view based on Cormack–Lehane grade, and a lower need for ELM, but comparable first intubation attempt success rate and overall intubation success rate compared with DL.

Impact of Videolaryngoscopy Expertise on First-Attempt Intubation Success in Critically Ill Patients.

The use of a videolaryngoscope in the ICU on the first endotracheal intubation attempt and intubation-related complications is controversial. The objective of this study was to evaluate the first intubation attempt success rate in the ICU with the McGrath MAC videolaryngoscope (Medtronic, Minneapolis, MN) according to the operators' videolaryngoscope expertise and to describe its association with the occurrence of intubation-related complications. Observational study. Medical ICU. Consecutive endotracheal intubations in critically ill patients. Systematic use of the videolaryngoscope. We enrolled 202 consecutive endotracheal intubations. Overall first-attempt success rate was 126 of 202 (62%). Comorbidities, junior operator, cardiac arrest upon admission, and coma were associated with a lower first-attempt success rate. The first-attempt success rate was less than 50% in novice operators (1-5 previous experiences with videolaryngoscope, independently of airway expertise with direct laryngoscopies) and 87% in expert operators (> 15 previous experiences with videolaryngoscope). Multivariate analysis confirmed the association between specific skill training with videolaryngoscope and the first-attempt success rate. Severe hypoxemia and overall immediate intubation-related complications occurred more frequently in first-attempt failure intubations (24/76, 32%) than in first-attempt success intubations (14/126, 11%) (p < 0.001). We report for the first time in the critically ill that specific videolaryngoscopy skill training, assessed by the number of previous videolaryngoscopies performed, is an independent factor of first-attempt intubation success. Furthermore, we observed that specific skill training with the McGrath MAC videolaryngoscope was fast. Therefore, future trials evaluating videolaryngoscopy in ICUs should consider the specific skill training of operators in videolaryngoscopy.

Study on the use of CT three-dimensional reconstruction technique for guiding tracheal intubation with rigid fiber bronchoscope in difficult airway

OBJECTIVE To evaluate the significance of CT three-dimensional reconstruction technique for guiding tracheal intubation with rigid fiber bronchoscope in difficult airway. METHODS In this study, 44 patients undergoing selective operation of ASA (American Society of Anesthesiologists physical status) I to II, neck stiffness, neck trauma needed braked, or severe cervical spondylosis were selected. The patients were randomly divided into two groups: 24 cases in the experimental group (group E) and 20 cases in the control group (group C). The stylets of the rigid fiber bronchoscopes were shaped according to the CT three-dimensional reconstruction images and parameters obtained before surgery. The rigid fiber bronchoscopes shaped according to the CT three-dimensional reconstruction images were used in group E, while the rigid fiber bronchoscopes with the original angles were used in group C. Tracheal intubation operations were all performed by an anesthesiologist who had more than 10 years' clinical experience and mastered in rigid endoscopic intubation techniques. The first attempt success rate and the total success rate of tracheal intubation, intubation time, blood pressure, heart rate and pulse oxygen saturation at different time points including pre-induction, immediately after intubation, 1-5 minutes after intubation, and intubation related complications within 24 hours were recorded. RESULTS The total success rate of intubation in the two groups were both 100%. The first attempt success rate of intubation was 96% in group E, and 70% in group C. The first attempt success rate of group E was higher than that of group C. The intubation time of group E was (20.7± 10.6) s, and (21.5 ± 17.6) s of group C. Group E was shorter than that of group C, but there was no significant difference (P > 0.05). RPP equaled the product of heart rate and systolic pressure, which represented the stress reaction of intubation on hemodynamics, was lower in group C at T0, T1, T2, T4 and T5 separately than that in group E, but there was no significant difference (P>0.05). There was no significant difference in tracheal intubation related complications between the two groups (P>0.05). CONCLUSION CT three-dimensional reconstruction technique has certain guiding significance in difficult tracheal intubation with rigid fiber bronchoscope in patients with fixed cervical spine.

Efficacy and safety of Cohen Flex-Tip blocker and left double lumen tube in lung isolation for thoracic surgery: a randomized comparative study

BackgroundThe Cohen blocker is one of the lung isolation devices. Unfortunately, most anesthesiologists believe that its efficacy in inducing lung collapse is less than that of the double-lumen tube (DLT). This study has been performed to compare the adequacy of lung collapse and the adverse effects between the Cohen blocker and the left DLT for thoracic operations.MethodForty patients with an age range of 25–50 years and American Society of Anesthesiologist (ASA) physical status I-II of either sex were subjected to an elective thoracic operation with lung isolation achieved by either a left DLT or a Cohen blocker. The patients were distributed randomly into two equal groups (n = 20): group (I) left DLT and group (II) Cohen-blocker. The following parameters were measured: the number of intubation attempts, time for correct positioning, and lung collapse assessment grades either spontaneous (grade 1), assisted with suction (grade II), or with manual disconnection maneuver (grade III). Sore throat and hoarseness were compared between the two groups.ResultsThe first intubation attempt success rate was 90% and 95% (p = 0.871), while the second attempt success rate was 10% and 5% (p = 0.617) in the left DLT and Cohen blocker groups, respectively (non-significant p value). The time for correct positioning was significantly shorter in the left DLT group than in the Cohen blocker group (p < 0.001). Lung collapse showed similar results between the two groups (p = 0.803) regardless of the grade of lung collapse: either spontaneous (grade I), assisted with suction (grade II), or with manual disconnection maneuver (grade III). The left DLT group showed a significantly higher frequency of hoarseness (p = 0.017) and sore throat (p = 0.028) than the Cohen blocker group.ConclusionWe concluded that Cohen blocker can be used as a good alternative to the left DLT for its efficiency in inducing lung collapse with minimal incidence of postoperative hoarseness and sore throat.

Comparision of intubation with polyvinyl chloride tracheal tubes and silicone wire reinforced tubes through LMA CTrach&lt;sup&gt;tm&lt;/sup&gt;

LMA CTrachTM enables ventilation and intubation with the same device while visualising the process of intubation. The manufacturer produced silicone wire reinforced tubes are recommended for intubation through this device. Objective: The intubation success rates with polyvinyl chloride tube and silicone wire reinforced tubes while intubating through LMA CTrachTM was compared. Study design: One hundred patients of ASA physical status 1 and 2 who were undergoing procedures under general anaesthesia were randomly allocated into two groups. In one group silicone wire reinforced tubes and in the other group polyvinyl chloride tracheal tubes were used for intubation through LMA CTrachTM. The success, number of attempts, time taken and the ease of intubation along with any incidence of airway trauma were recorded. Results: The overall success rate of intubation was 100% in both groups. The first attempt success of intubation was significantly higher in silicone tube group (98%) as compared to polyvinyl chloride tube group (84%). The ease of intubation was significantly higher in silicone tube group (98% versus 80%). The time taken for intubation was longer with polyvinyl chloride tube group by a mean of 10 seconds. The incidence of airway trauma was comparable in both groups. Conclusion: Polyvinyl chloride tracheal tubes can be used instead of the silicone wire reinforced tubes for intubating through LMA CTrachTM with a similar overall success rate and incidence of airway trauma. However, the first attempt success rate of intubation and ease of intubation were higher with the silicone wire reinforced tube.

Clinical Impact of External Laryngeal Manipulation During Laryngoscopy on Tracheal Intubation Success in Critically Ill Children.

External laryngeal manipulation is a commonly used maneuver to improve visualization of the glottis during tracheal intubation in children. However, the effectiveness to improve tracheal intubation attempt success rate in the nonanesthesia setting is not clear. The study objective was to evaluate the association between external laryngeal manipulation use and initial tracheal intubation attempt success in PICUs. A retrospective observational study using a multicenter emergency airway quality improvement registry. Thirty-five PICUs within general and children's hospitals (29 in the United States, three in Canada, one in Japan, one in Singapore, and one in New Zealand). Critically ill children (< 18 years) undergoing initial tracheal intubation with direct laryngoscopy in PICUs between July 1, 2010, and December 31, 2015. Propensity score-matched analysis was performed to evaluate the association between external laryngeal manipulation and initial attempt success while adjusting for underlying differences in patient and clinical care factors: age, obesity, tracheal intubation indications, difficult airway features, provider training level, and neuromuscular blockade use. External laryngeal manipulation was defined as any external force to the neck during laryngoscopy. Of the 7,825 tracheal intubations, the initial tracheal intubation attempt was successful in 1,935/3,274 intubations (59%) with external laryngeal manipulation and 3,086/4,551 (68%) without external laryngeal manipulation (unadjusted odds ratio, 0.69; 95% CI, 0.62-0.75; p < 0.001). In propensity score-matched analysis, external laryngeal manipulation remained associated with lower initial tracheal intubation attempt success (adjusted odds ratio, 0.93; 95% CI, 0.90-0.95; p < 0.001). External laryngeal manipulation during direct laryngoscopy was associated with lower initial tracheal intubation attempt success in critically ill children, even after adjusting for underlying differences in patient factors and provider levels. The indiscriminate use of external laryngeal manipulation cannot be recommended.

Evaluation of the Effect of Tracheal Tube Orientation on Success of Intubation through Intubating Laryngeal Mask Airway.

Polyvinyl Chloride Endotracheal Tube (PVC ETT) can be used as an alternative to Fastrach Silicone Wire-Reinforced Tube (FTST) for intubation through Intubating Laryngeal Mask Airway (ILMA) as the latter is expensive and has low volume high pressure cuff. To evaluate the effects of orientation of PVC ETT (normal curve and reverse curve) on the success of intubation through ILMA, haemodynamic response and postoperative sore throat. Sixty healthy adult patients of ASA physical status I & II scheduled for elective surgery under general anaesthesia requiring endotracheal intubation were randomly divided into two groups. In Normal (N) group (n=30), the tracheal tube was inserted with its natural curve following the 90° curvature of ILMA. In Reverse (R) group (n=30), the tracheal tube was inserted with its natural curve directed opposite to the curvature of ILMA. The time taken to intubate, number of attempts, and maneuvers required for successful endotracheal intubation along with haemodynamics and oxygen saturation were noted. Postoperative sore throat was evaluated using a Verbal Analogue Scale (VAS) (0-10). Qualitative data was analysed by Chi-Square test and Fisher's exact test. Quantitative data was analysed by unpaired t-test and Mann-Whitney test. Placement of ILMA was successful in all patients. Total Intubation Time (mean±SD) in Group N was 12.53±1.78 seconds and in Group R was 11.97±1.33 seconds (p>0.05). Tracheal intubation through ILMA was successful in all patients. First attempt success rate in R Group (26 patients, 86.7%) was higher than N Group (22 patients, 73.3%) (p>0.05). Four patients (13.3%) in R Group and 8 patients (26.7%) in N Group required 2nd step of Chandy's maneuver during second attempt for successful intubation. Incidence of sore throat 6 hours postoperatively was statistically significant (median value 2.00 in N Group vs. 0.00 in R Group) between two groups. PVC ETT with reverse orientation increases first attempt success rate of intubation through ILMA with less immediate postoperative laryngeal morbidity.

463: First-Attempt Success Rate of Endotracheal Intubation Performed by Air Medical Providers In Various Settings

Endotracheal intubation (ETI) in the air medical setting can be challenging, yet is commonly required of air medical providers. Understanding ETI failure rate and associated factors could improve training and increase ETI success rate in the air medical setting. We endeavored to calculate overall first-attempt success rates for air medical providers performing ETI in various settings and identify factors that may affect first-attempt success rate. Patients were enrolled in a prospective observational Air Care Airway Registry from January 2000 to March 2002, and from April 2004 to May 2007. Patients requiring advanced airway management performed by a member of the air medical flight crew (flight registered nurse and flight physician) were eligible for enrollment. The flight physician was most often an emergency medicine resident post-graduate year (PGY) 2-4, but on occasion was an attending emergency physician. An additional PGY-1 emergency physician was present on some flights. Cases were included in this analysis if the site where advanced airway management was performed, and the crew member performing the procedure, was recorded. The Chi Square or Fisher's Exact test was used to compare differences in categorical variables and Student's t-tests were used for continuous variables. From 305 patients enrolled, 291 patients were included in this analysis. Mean age was 36 (SD 21), mean weight was 79 kg (SD 27) and 70% were male. The first crew member attempting advanced airway management was most often a PGY-2 physician (51%) or a flight nurse (25%). The first advanced airway management attempt most often occurred in the ambulance (54%). Overall, the success rate of ETI on first attempt was 69.2% [95CI 62.3% to 73.3%]; 96.6% of patients were intubated in less than four attempts and there were up to 6 attempts in one case. Success on first attempt did not vary by provider type overall (p=0.076), or when ETI was attempted in an ambulance (p=0.392), at the scene (p=0.975), or in the helicopter (p=0.762). PGY-1 physicians were less likely to have first attempt success in an outside hospital (p=0.021). While the first attempt success rate appeared higher in a hospital setting, this did not reach significance (p=0.962), and there was no statistical evidence for differing success rates across the site of first attempt. Weight and age were not associated with initial intubation success. Males were more likely than females to require multiple airway management attempts (p =0.016). Table 1. First intubation attempt success rate by location.Tabled 1 The success of the first intubation attempt for air medical providers in this single center registry was similar to that found in other studies. The success rate appears consistent regardless of who attempts the procedure or where the attempt is made, although site and provider are not independent. Males required multiple intubation attempts more often than females; elucidating why this occurs requires further exploration of possible confounders.

The LMA CTrach™, a new laryngeal mask airway for endotracheal intubation under vision: evaluation in 100 patients

The LMA CTrach is a new laryngeal mask system consisting of an LMA CTrach Airway with integrated fibreoptic channels, and a detachable LMA CTrach Viewer. This system enables viewing of the larynx and aids endotracheal intubation through a laryngeal mask airway. Method. We used and evaluated this system in 100 adult patients undergoing general anaesthesia for elective surgery. Our primary outcomes were the success rates of LMA CTrach Airway insertion and endotracheal intubation with this system. We were able to insert the LMA CTrach Airway in and to ventilate all 100 patients. We were successful in endotracheal intubation, either under vision or blind, in 96 patients. We were able to view the larynx in 84 patients, but the quality of the best view obtained was very variable. The median (inter quartile range) time for the complete intubation process was 166 (114-233) s. The system allowed nearly continuous ventilation and oxygenation during the process. The LMA CTrach system has potential advantages over the LMA Fastrach system, including the ability to align the LMA outlet with the larynx and a high first intubation attempt success rate. However, it was difficult to view the larynx with the LMA CTrach compared with direct laryngoscopy, and expectations must be moderated.