Laryngeal View Research Articles

Oesophageal intubations in anaesthetic practice across Australia and New Zealand: A webAIRS analysis of 109 incidents.

Oesophageal intubations are more common than may be realised and can potentially cause significant patient harm even if promptly identified and corrected. Reports of morbidity due to unrecognised oesophageal intubation continue to present in coroner and media reports. Therefore, it would be helpful to identify mechanisms to prevent these events and implement strategies to avoid and identify incorrect endotracheal tube placement. This analysis of oesophageal intubations reported to webAIRS aims to provide an in-depth analysis of all events in which oesophageal intubation occurred. WebAIRS is a web-based, bi-national incident reporting system collecting voluntarily reported anaesthetic events across Australia and New Zealand, with more than 10,500 incidents registered. A structured search through the webAIRS database identified 109 reports of oesophageal intubation reported between July 2009 and September 2022. A common cause of oesophageal intubation was the misidentification of the larynx due to a poor laryngeal view. Desaturation directly attributed to the misplaced endotracheal tube occurred in 43% of all reports. The authors precisely defined early recognised oesophageal intubation and delayed or unrecognised oesophageal intubation. Most reports (74%) described early recognition of the misplaced intubation, of which 27% led to directly contributed to hypoxia. Cardiovascular collapse as a direct consequence of the late recognition of oesophageal intubation was described in five (18%) of these events. There was inconsistency in end-tidal carbon dioxide monitoring and interpretation of the resulting waveform. Findings show that oesophageal intubation continues to be an issue in anaesthesia. Incidents described confusion in diagnosis, human factors issues and cognitive bias. Clear diagnostic guidance and treatment strategies are required to be developed, tested and implemented.

A comparative study of head-elevated positions at 25° versus 45° for intubation in obese patients posted for elective surgery under general anesthesia

Background: Obese patients generally present with an increased risk of difficult intubation. The head-elevated position has been shown to improve laryngeal view, reduce airway complications, and prolong safe apnea time during intubation as compared to the sniffing position. Aims and Objectives: The aim of this study is to compare the head-elevated positions at 25° versus 45° for intubation in obese patients, in terms of ease of intubation assessed by first-attempt intubation success rate and laryngeal exposure using Cormack–Lehane grading and to assess intubation time, use of intubation aides, changes in hemodynamic parameters, and hypoxia. Materials and Methods: In this randomized controlled trial, 100 consenting patients undergoing elective surgery requiring general anesthesia were selected who fulfilled the eligibility criteria and assigned to either of the two groups by block randomization: Group A – 25° or Group B – 45° head-elevated positions for intubation in a tertiary care hospital (February 2021–July 2022). Results: The 45° head-elevated position was found to provide a better laryngeal exposure, the mean time to intubate was lesser and the first attempt success rate was also higher. Further, 45° head-elevated position is better chosen as per anesthesiologist comfort, using Likert scale grading. Conclusion: This study concluded that 45° head-elevated position provides better ease of intubation in obese patients as compared to 25° head-elevation.

Use of Video Laryngoscope during Intubation in Patients with Non Difficult Airway

Endotracheal intubation using laryngoscope which is an important skill required for all anesthesiologist in day to day practice is considered as gold standard for airway management. Various methods can be used for endotracheal intubation of which direct laryngoscopy is most commonly used and video laryngoscopy is an alternative. The success rate of tracheal intubation in cases of difficult airways has increased dramatically with the use of video laryngoscopes and improvements in the degree of glottic exposure. Hence this study aims to evaluate the laryngoscopic view, ease of intubation and haemodynamic changes during intubation using video laryngoscope in patients with non difficult airway. This interventional study was conducted in fifty nine patients of ASA I or II, ≥18 yrs of age with Mallampati grade I or II, mouth opening >3 cms, thyromental distance >6.5 cms of either sex planned for elective surgery under general anesthesia. General anesthesia was induced with similar doses for all the patients and intubated using video laryngoscope. Cormack-Lehane grade, intubation time, number of attempts for intubation and haemodynamic parameters were recorded. In this study, all patients had grade I type of laryngeal view during laryngoscopy and the mean time required for intubation was 18.93±7.08 sec. Out of 59 patients, 58 (98.3%) were intubated in single attempt and there was no significant haemodynamic changes during laryngoscopy with video laryngoscope. Hence, the result of this study concluded that endotracheal intubation using video laryngoscope provides good laryngoscopic view, better intubating condition for the ease of intubation without significant haemodynamic changes, thus considering worth for intubation of non difficult airway.

Comparison of channelled with non-channelled blade of King Vision videolaryngoscope for orotracheal intubation in patients undergoing emergency surgery: A randomised double blind study

BackgroundPatients undergoing emergency surgery can have both anatomical and physiological difficult airways. There being no consensus on the best strategy to secure such airways, hence the present study evaluated the clinical performance of the two blades of King Vision™ Videolaryngoscope (KVVL). MethodsThis prospective double blind study was done on fifty two patients of 18–80 years aged posted for emergency surgery under general anaesthesia (GA). Patients were randomly assigned to channelled (CH) and non-channelled (NC) group for intubation. The primary outcome was time to tracheal intubation with CH and NC blades. The secondary outcomes among the two groups noted were ease of videolaryngoscope (VL) blade insertion, time to optimal laryngeal view, fremantle score, number of intubation attempts, any manoeuver required to intubate and complications. Haemodynamic parameters were noted before induction, during preoxygenation before laryngoscopy and 5 min after endotracheal intubation. ResultsSignificant shorter time to intubation was noted in NC group (18s) compared with CH group (25s). The NC blade was easier to insert and the time to optimal laryngeal view was also shorter with NC group (7s) as compared to CH group (10s). Fremantle score was comparable among the two groups. Endotracheal tube (ETT) impingment on arytenoids was more common with NC blade. For intubation with CH blade, anticlockwise rotation of ETT was frequently required. ConclusionThe NC blade of KVVL was easier to introduce and resulted in faster intubation, thus favouring its use in patients undergoing emergency surgery under GA. The CH blade of KVVL required anticlockwise rotation to facilitate intubation.

Comparison of Paraglossal Technique of Miller Blade Insertion with McCoy and Macintosh Adult Laryngoscopes on the Cormack–Lehane Grade in Patients with Simulated Restricted Neck Mobility—A Randomized Control Trial

Abstract Background The paucity in round-the-clock availability of advanced tools like flexible bronchoscopes and video laryngoscopes makes it preferable to have alternative easily available gadgets for securing the airway in patients with cervical spine injuries where head and neck movements must be strictly avoided. This study compared the paraglossal technique of Miller blade insertion with the McCoy and Macintosh laryngoscope blades on the Cormack and Lehane grading (CLG) in patients with simulated restricted neck mobility. Methods We randomized 90 patients undergoing general anesthesia to be intubated either using Miller blade (Group-Mill), McCoy blade (Group-McCoy), or Macintosh blade (Group-Mac) following neck restriction using a soft cervical collar. CLG grade, the number of intubation attempts, use of bougie, intubation time, and hemodynamic parameters were noted. Nonparametric data were compared using the chi-squared test and parametric data using one-way analysis of variance. Results Group-MILL had significantly higher patients with Grade-1 CLG compared to Group-Mac (p = 0.02). The number of attempts, use of bougie, and intubation time were, however, comparable among the three groups. The hemodynamic parameters at intubation were not significantly different among the groups. Conclusion In adult patients with simulated restricted neck, the Miller laryngoscope blade, despite providing a better laryngeal view, showed no benefit in decreasing the intubation time when compared to the McCoy or Macintosh blades.

Comparative evaluation of self-pressurized Air-Q® and Proseal™ LMA® in patients undergoing elective surgery under general anaesthesia: A randomized clinical trial.

Intra-cuff pressure of Air-Q self-pressurized laryngeal airways (Air-Q SP) balances airway pressure and adapts to patient's pharyngeal and periglottic structures, thus improves oropharyngeal leak pressure (OLP).This study was performed to compare efficacy of Air-Q SP with Proseal laryngeal mask airway (PLMA) in patients undergoing elective surgery. The study design was prospective, randomized and controlled. Ninety patients were randomly assigned to Air-Q SP or PLMA group. All patients were premedicated and shifted to operation theatre. Monitoring was instituted. After securing IV-line, induction with inj. Morphine + Propofol, relaxation with inj. Vecuronium was done. Supraglottic was inserted according to group allocation. Outcome measures were OLP, fibreoptic view of larynx, success rate, device insertion parameters, haemodynamic and respiratory parameters and post-operative laryngopharyngeal complications. Neostigmine + glycopyrrolate were given, device was extubated. All supraglottic airway devices (SADs) were successfully placed in two attempts. The mean initial OLP, OLP at 10 minutes, and device insertion time were significantly lower in Air-Q SP group. Fiber-optic laryngeal view grading was significantly better with Air-Q SP. No significant difference was observed with respect to rate of successful insertion in first attempt, ease of insertion, and manipulations required. The hemodynamic/respiratory parameters and post-operative sore throat in the two both groups were similar. Proseal LMA has a higher OLP than Air-Q SP but average insertion time was better, and fiber-optic grading of laryngeal view was shorter with Air-Q SP. However, Air-Q SP and Proseal LMA were both effective for lung ventilation.

Influence of different head and neck positions on performance characteristics of second generation supraglottic airway devices

BackgroundVarious head and neck positions alter the performance of supraglottic airway devices (SAD). We compared the influence of flexion, extension, neutral and rotation of the neck on performance characteristics of second generation airway devices namely Proseal (PLMA), i-gel and Auragain laryngeal mask. MethodsThis study was conducted in 90 ASA physical status I and II patients 18–65 years of age. Patients were randomised into three groups with 30 patients in each: PLMA, i-gel and Auragain. The primary objective was to compare oropharyngeal leak pressure (OPLP) among PLMA, i-gel and Auragain in neutral, flexion, extension and lateral rotation of the neck. The secondary objective was to compare Peak inspiratory pressure (PIP), ventilation score, expired tidal volume, fiberoptic grading of laryngeal view, end tidal carbon dioxide and OPLP-PIP difference. ResultsPLMA, i-gel and Auragain have the highest OPLP in flexion (34.4 ± 2.5, 31.6 ± 2.3, 32.8 ± 1.7) followed by neutral, left lateral rotation and lowest in extension (26.7 ± 1.6, 25.4 ± 3.19, 29.6 ± 1.0) respectively. PLMA and Auragain have significantly higher OPLP when compared to i-gel in all positions p < 0.05. In extension, OPLP with Auragain (29.6 + 1.0) was significantly higher than PLMA (26.7 + 1.6) and i-gel (25.4 + 3.1), p < 0.001. PIP was significantly higher in flexion position for all the three devices. No significant difference in fibre optic grading and ventilation score was seen for three devices in various neck positions. ConclusionsPLMA and Auragain have better sealing pressure than i-gel in all the positions. Flexion position during surgery is best for maintaining OPLP. Auragain should be preferred over PLMA and i-gel in surgeries involving extension of neck.

Comparing Ambu AuraGain™ Disposable Laryngeal Mask with i-gel™ as a conduit for fibreoptic guided tracheal intubation for elective surgery under general anaesthesia in adult patients

BackgroundSupraglottic airway devices (SADs) have emerged as an alternative for airway management, serving as conduits for tracheal intubation with fibreoptic bronchoscopy (FOB). In this study, we aim to compare the efficacy of two SADs for FOB guided tracheal intubation in adult patients undergoing elective surgery. Methods120 patients were randomly assigned to two groups Group A (i-gel™) or Group B (Ambu AuraGain™ Disposable Laryngeal Mask). The ease of insertion, time for successful placement, number of attempts, need for manipulation, time for FOB intubation and laryngeal view were recorded. ResultsThe first pass success rate of intubation through either SAD was 100% (p = 1). Group A had a significantly higher ease of insertion score of 1 than Group B (63.33% vs 38.33%, p = 0.003). The time required for successful placement of the device was significantly longer in Group B than in Group A (17.44 ± 5.46 s vs13.62 ± 4.67 s, p = 0.001). The mean ± SD of time for FOB guided intubation(seconds) in group A was 66.59 ± 21.42 which was significantly higher as compared to group B (55.93 ± 19.79) (p value = 0.005). Conclusion: Our study compared i-gel™ and Ambu AuraGain™ for FOB-guided tracheal intubation and found both SADs equally effective with similar laryngeal views. Despite i-gel's superior ease of insertion, shorter time for insertion and fewer airway manipulations for insertion, Ambu AuraGain™ exhibited a shorter intubation time. Incidences of intraoperative and postoperative complications were comparable. Clinicians should choose the SAD based on preference and familiarity.

Comparison of Time Taken for Intubation (TTI) in Conventional Laryngoscope with Video Laryngoscope for Endotracheal Intubation In Laproscopic Surgeries

Background: Direct laryngoscopy necessitates the alignment of the oropharyngeal-laryngeal axis whereas video laryngoscope is an optical vision which doesn’t require alignment. This study aimed to compare direct laryngoscopy with a Macintosh blade to King-Vision Video laryngoscope for endotracheal intubation in patients who were scheduled for elective laproscopic surgeries under general anaesthesia.&#x0D; Methods: In this prospective randomised clinical study,118 adults with ASA I and II requiring endotracheal intubation for laproscopic surgeries under general anaesthesia were enrolled and randomised into either of the two groups by envelope method, Group DL-direct laryngoscope and Group VL-video laryngoscope where they were intubated using direct laryngoscope with Macintosh blade or King Vision videolaryngoscope. The Primary objective was to compare Time to intubate(TTI), Visualization of the laryngeal view by Cormack-Lehane grade and Successful first attempt. Secondary objective was to record the Number of intubation failure, Number of attempts, Change of anaesthesiologist and use of adjunct equipment and the complications such as oropharyngeal trauma, neck pain, dysphagia and hoarseness.&#x0D; Results: In comparison to group DL (21.67±4.318s), group VL took longer time to intubate (26.21± 4.150s) but had superior glottic vision than DL group(p=0.0177). Compared to DL group (72.4%), the VL (84.5%) patients had their first successful attempt, inspite of 2 failures. Complications such as pharyngeal pain (8.6%vs29.3%), hoarseness (5.2%vs29.3%), Use of adjunct equipment like bougie (19%vs 3.4%) were significantly higher in DL compared to VL group, while oropharyngeal injury, dysphagia, number of attempts and change of anaesthetists were similar in both groups.&#x0D; Conclusion: In comparison to the Macintosh laryngoscope, the King-vision VideoLaryngoscope took longer to intubate but had clearer glottis visualisation and a higher first-time success rate and can be used as a good teaching tool. In King-vision video laryngoscope, there was less use of auxiliary equipment and fewer complications.

Effect of Video laryngoscope on Tp-e Interval, Qtc and Tp-e/Qtc Ratio Compared with Direct Laryngoscope in Patients With Double-Lumen Tube Undergoing Thoracic Surgery

Aim: QT interval is generally related to the increased risk of polymorphic ventricular tachycardias and ventricular arrythmias. Intubation and laryngoscopy might change in cardiac repolarization and an increase in QT interval length. Video laryngoscopes provide better laryngeal view, higher intubation success, and better correct positioning on double-lumen tube (DLT) intubation. We aimed to compare McGRATH MAC 5 video laryngoscope to direct Macintosh laryngoscope and their effects on Tp-e interval, QTc and Tp-e/QTc ration in those patients requiring intubation having DLT. Materials and Methods: The randomly controlled prospective work is carried out on 94 patients, scheduled for thoracic surgery, aged between 18-65. After anaesthetic induction and before tracheal intubation, all patients airway were evaluated Cormack and Lehane in using a Macintosh laryngoscope and patients having Cormack and Lehane grade-1 or -2a views included in study. The patients who are intubated with video laryngoscope (McGRATH MAC) are allocated into Group V and intubated with direct Macintosh Laryngoscope was allocated into Group L. The primary aim was compared between the two devices on Tp-e interval, QTc and Tp-e/QTc ratio with ECG recordings. The secondary goal was assessment of hemodynamic status and intubation conditions. Results: In Group V, QTc interval, Tp-e intreval and Tp-e/QTc ratio was lower in a significant way than Group L. There has not been a significant difference in terms of hemodynamic assessment among those two groups at all measurement periods. Cormack-Lehane scores, intubation times, DLT types and sizes were similar between two groups. Conclusion: McGRATH MAC video laryngoscope decreased Tp-e interval, QTc and Tp-e/QTc ratio compared to direct Maintosh laryngoscope. Hemodynamic response and intubation parameters are seen as similar to each other in both of the present groups.

A randomised controlled trial to compare blind intubation success through LMA Blockbuster® and I-Gel® LMA.

Laryngeal mask airway-blockbuster (LMA-BT) is a relatively new supraglottic airway device (SGAD). In this study, we compared LMA-BT with I-Gel LMA for efficacy of blind tracheal intubation. We conducted a single-blind prospective study after ethical approval. One hundred American Society of Anesthesiology (ASA) Grade I-III (age 18-60 years) patients scheduled for elective surgery under general anaesthesia with endotracheal intubation were included and randomly divided into 2 groups. Blind tracheal intubation was performed through LMA-BT ( n = 50) and I-Gel ( n = 50) in groups 1 and 2, respectively. The primary aim was to evaluate the first pass success rate of blind tracheal intubation through the LMAs. The secondary objectives noted were attempts and ease of LMA insertion, total time taken for LMA insertion, airway seal pressure of LMA, ease of NGT insertion through LMA, fibre-optic grading of laryngeal view through LMA, overall success rate and time of intubation through LMA, time for LMA removal, and complications, if any. In the LMA-BT group, the first pass success rate ( P < 0.019) and the overall success rate of intubation ( P < 0.005) were significantly higher than in the I-Gel group. Using LMA-BT also resulted in statistically significant shorter intubation time ( P < 0.0001) with higher airway seal pressure as compared to I-Gel ( P < 0.001). The difference in the first attempt insertion, number of insertion attempts, ease and time of LMA insertion and removal after intubation, and postoperative complications were comparable among the groups. LMA-BT is a superior device as compared to I-Gel LMA as a conduit for blind tracheal intubation.

A comparative evaluation of the sniffing, the simple head extension and the head hyperextension positions for laryngoscopic view and intubation difficulty in adults undergoing direct laryngoscopy

ObjectiveThis work aimed to compare between the laryngoscopy positions; sniffing, simple head extension and head hyperextension positions to assess whether the laryngeal view, intubation time and intubation difficulty could improve with one of these positions than the others.DesignProspective randomized three arms clinical trial.SettingOperation room, the phoniatrics unit [removed for blind peer review].ParticipantsThe study included 75 cases with 25 cases in each group. Group "A" with head in the sniffing position, Group "B" with the head in simple extension position, Group "C" with head in hyperextension position.ResultsThe three groups were compared regarding intubation time and laryngoscopic view time. Intubation time showed statistically significant difference between the three groups. Mean of sniffing group (No. = 25) was 13.19 s (± 3.35). Mean of simple extension group (No. = 25) was 11.29 s (± 3.14). Mean of Hyperextension group (No. = 25) was 14.39 s (± 4.14). Laryngoscopic view time showed statistically highly significant difference between the three groups. Mean of sniffing group (No. = 25) was 17.19 s (± 7.27). Mean of simple group (No. = 25) was 12.18 s (± 4.46). Mean of hyperextension group (No. = 25) was 17.08 s (± 6.51).ConclusionComparing the sniffing, the simple extension and the hyperextension positions, the simple extension position showed the best time regarding intubation time and laryngoscopic view time.

Complications and degree of difficulty of orotracheal intubation in the Intensive Care Unit before and after the establishment of an intubation protocol for critically ill patients: a prospective, observational study

ObjectiveThe objective of our study was to compare the degree of difficulty and complications related to tracheal intubation in an Intensive Care Unit (ICU) before and after the introduction of an intubation protocol based on the Difficult Airway Society guidelines for the management of tracheal intubation in critically ill adults, published in 2018. MethodsProspective, observational study comparing all intubations performed in our ICU over 2 periods: pre-protocol (January 2015–January 2019) and post-protocol (February 2019–July 2022). The material used for intubation, the degree of difficulty, and intubation-related complications were recorded. ResultsDuring the study period, 661 patients were intubated - 437 in the pre-protocol period (96% by direct laryngoscopy) and 224 in the post-protocol period (53% with direct laryngoscopy, 46% with video laryngoscopy). We observed an improvement in laryngeal view in the post-protocol period compared to the pre-protocol period (Cormack–Lehane ≥ 2b in 7.6% vs. 29.8%, p < 0.001), and a decrease in the number of moderate-to-severely difficult intubations (6.7% vs. 17.4%, p < 0.001). The first-pass success rate was 92.8% in the post-protocol period compared to 90.2% pre-protocol (p = 0.508). We did not find significant differences in complications between the periods studied. ConclusionsIntubations performed in the post-protocol period were associated with improved laryngeal view and fewer cases of difficult intubation compared with the pre-protocol period.

Complicaciones y grado de dificultad de la intubación orotraqueal en la unidad de cuidados intensivos pre-post instauración de un protocolo de intubación para el paciente crítico. Estudio prospectivo y observacional

ObjectiveThe objective of our study was to compare the degree of difficulty and complications related to tracheal intubation in an intensive care unit (ICU) before and after the introduction of an intubation protocol based on the Difficult Airway Society guidelines for the management of tracheal intubation in critically ill adults, published in 2018. MethodsProspective, observational study comparing all intubations performed in our ICU over two periods: pre-protocol (January 2015-January 2019) and post-protocol (February 2019-July 2022). The material used for intubation, the degree of difficulty, and intubation-related complications were recorded. ResultsDuring the study period, 661 patients were intubated —437 in the pre-protocol period (96% by direct laryngoscopy) and 224 in the post-protocol period (53% with direct laryngoscopy, 46% with video laryngoscopy). We observed an improvement in laryngeal view in the post-protocol period compared to the pre-protocol period (Cormack-Lehane ≥2b in 7.6% vs 29.8%, P<.001), and a decrease in the number of moderate-to-severely difficult intubations (6.7% vs 17.4%, P<.001). The first-pass success rate was 92.8% in the post-protocol period compared to 90.2% pre-protocol (P=.508). We did not find significant differences in complications between the periods studied. ConclusionsIntubations performed in the post-protocol period were associated with improved laryngeal view and fewer cases of difficult intubation compared with the pre-protocol period.

VIDEOLARYNGOSCOPE VERSUS TRADITIONAL LARYNGOSCOPY FOR COMPARISON OF EASE OF INTUBATION AND HEMODYNAMIC CHANGES – A PROSPECTIVE RANDOMIZED STUDY

Objective: The objective of the study is to compare ease of intubation and hemodynamic changes with video laryngoscope (VL) (C-MAC) versus traditional laryngoscopy and to assess any complication such as arrhythmias, local injuries, bleeding, laryngospasm, regurgitation during intubation, and sore throat post-intubation. Methods: This prospective randomized study was conducted on 200 patients of Mallampati (MP) Grades 1 and 2, ASA-PS I and II, randomly allocated to Group M (Macintosh) and Group V (C-MAC) (n=100 each). Hemodynamic changes (heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure [MAP], SpO2, and EtCO2) were recorded at baseline, during pre-oxygenation, during laryngoscopy, and during intubation, at 1 min, 3 min, 5 min, and then, at 10 min after endotracheal intubation. Ease of intubation and any complications were also recorded. Results: Laryngeal view was significantly better in Group V. The mean heart rate during laryngoscopy and intubation (L&amp;I) and after endotracheal intubation at 3rd min (ETI3); mean systolic blood pressure during L&amp;I and after ETI1, ETI3, and ETI5 min; mean diastolic blood pressure after ETI1 and ETI min; and mean MAP during L&amp;I and after ETI1 min were found to be significantly higher in Group M as compared to Group V (p&lt;0.05). The difference in mean SPO2 and ETCO2 between the two groups was not found to be significant at any time interval. No significant difference was observed with respect to complications. Conclusion: Group V (VL C-MAC) showed better ease of intubation, decreased hemodynamic response, and fewer complications as compared to Group M (Macintosh laryngoscope).

Effect of operation table height on ease of mask ventilation, laryngeal view, and endotracheal intubation success.

Optimal patient positioning and operating table height are essential for an ergonomic posture of an anesthesiologist in which there is minimal or no strain on thewrist during mask ventilation. It also avoids flexion of the neck, lower back, and knee bending at the time of laryngoscopy and intubation. One hundred eighty patients were randomly allocated to three groups based on different table heights. The height of the table is kept at the mid-sternum level of an anesthesiologist in group 1, at the xiphoid process in group 2, and at the level of umbilicus in group 3. Laryngoscopic view with or without postural changes (exertion at wrist joint, flexion of the neck, lower back, or knee bending) was graded as per Cormack Lehane's (CL) grading. The degree of discomfort experienced by the anesthesiologist during mask ventilation or tracheal intubation was graded subjectively (1 = no discomfort, 2 = mild discomfort, 3 = moderate discomfort, and 4 = severe discomfort) at different table heights. Postural changes required to obtain the best glottic view and quality of endotracheal (ET) intubation (intubation time and attempts required) were also noted. For analysis, quantitative variables were expressed as mean ± SD and compared using unpaired t or analysis of variance test. Qualitative variables were expressed as frequencies/percentages and compared using the Chi-square test. Results with P value <0.05 were considered significant statistically. Moderate discomfort (strain at wrist joint) during bag-mask ventilation was experienced by the anesthesiologist in a maximum number of patients in group 1 (81.7%). Significant improvement was seen in CL grade after the use of postural modifications in groups 1 and 2 (P value ≤0.05). Greater postural modifications were required during ET intubation at lower table heights (group 3). It is advisable to adopt higher table positioning in relation to anesthesiologist performing the laryngoscopy for smooth and single-attempt ET intubation since the best laryngoscopic view and intubation with minimal postural modifications was seen at higher table heights (at the mid-sternum level of an anesthesiologist).

A randomized comparison of the performance of Airtraq videolaryngoscope versus Macintosh laryngoscope in simulated rapid sequence induction of anaesthesia

Application of cricoid pressure during rapid sequence induction (RSI) of anaesthesia leads to difficult airway. No channeled videolaryngoscope (VL) has been compared with the Macintosh laryngoscope for facilitating intubation in RSI. Thus, we compared Airtraq® VL with Macintosh laryngoscope for simulated RSI in patients scheduled for elective surgeries.Following approval from Institutional Ethics Committee-Human Research, this randomized study was conducted. Patients of either sex, aged 18-65yr, ASA grade I/II, scheduled for elective surgeries under GA were included. 'Group DL' underwent direct laryngoscopy (DL) using Macintosh laryngoscope and Group VL with Airtraq® videolaryngoscope. Time taken for intubation, Cormack-Lehane (CL) grade of laryngeal view, number of intubation attempts, and haemodynamic parameters were noted. Student t-test and chi square test were used for statistical analysis.A total of 140 patients with 70 in each group were included. The mean time taken for intubation was significantly higher in VL group (84.70 ± 28.05s) than DL group (23.90 ± 6.67s). The optimal laryngeal view (i.e. CL grade I or II) was significantly improved in VL group than DL group i.e. 97% vs 94%. In group DL, 99% (n=69) were intubated in first attempt; whereas 60% (n=42) in Group VL (p&amp;#60;0.001). Hemodynamics was better in group VL.Airtraq® VL is better than conventional Macintosh laryngoscope for endotracheal intubation during RSI in terms of optimal glottic view, ease of intubation and haemodynamics. On the contrary, the “time taken to intubation” and the first attempt intubation rate were higher with Airtraq® VL.

Identifying Laryngeal Neoplasms in Laryngoscope Images via Deep Learning Based Object Detection: A Case Study on an Extremely Small Data Set

ObjectivesLaryngoscopy is a medical procedure for obtaining a view of the human larynx. It is challenging for clinicians to distinguish laryngeal neoplasms by human visual observation. Recent deep learning methods can assist clinicians in improving the accuracy of distinguishing. However, existed methods are often trained on large-scale private datasets, while other researchers and hospitals can neither access these private datasets nor afford to build such large-scale datasets. In this paper, we focus on identifying laryngeal neoplasms under the “small data” regime, which is more important for many small hospitals to investigate deep learning models for diagnosis. Material and methodsWe build an extremely small dataset consisting of 279 laryngoscopic images of different categories. We found that traditional deep learning models for image classification cannot achieve satisfactory performance for small data, due to the great variability of recording laryngoscopic images and the small area of the neoplasms. To address these difficulties, we propose to employ object detection methods for this small data problem. Concretely, a Faster R-CNN is implemented here, which combines the DropBlock regularization technique to alleviate overfitting additionally. ResultsCompared to previous methods, our model is more robust to overfitting and can predict the location and category of detected neoplasms simultaneously. Our method achieves 73.00% overall accuracy, which is higher than the average of clinicians (65.05%) and the recent state-of-the-art classification method (65.00%). ConclusionThe proposed method shows great ability to detect both the category and location of neoplasms and can be served as a screening tool to help the final decisions of clinicians.

Airway Management: The Current Role of Videolaryngoscopy.

Airway management is usually an uncomplicated and safe intervention; however, when problems arise with the primary airway technique, the clinical situation can rapidly deteriorate, resulting in significant patient harm. Videolaryngoscopy has been shown to improve patient outcomes when compared with direct laryngoscopy, including improved first-pass success at tracheal intubation, reduced difficult laryngeal views, reduced oxygen desaturation, reduced airway trauma, and improved recognition of oesophageal intubation. The shared view that videolaryngoscopy affords may also facilitate superior teaching, training, and multidisciplinary team performance. As such, its recommended role in airway management has evolved from occasional use as a rescue device (when direct laryngoscopy fails) to a first-intention technique that should be incorporated into routine clinical practice, and this is reflected in recently updated guidelines from a number of international airway societies. However, currently, overall videolaryngoscopy usage is not commensurate with its now widespread availability. A number of factors exist that may be preventing its full adoption, including perceived financial costs, inadequacy of education and training, challenges in achieving deliverable decontamination processes, concerns over sustainability, fears over "de-skilling" at direct laryngoscopy, and perceived limitations of videolaryngoscopes. This article reviews the most up-to-date evidence supporting videolaryngoscopy, explores its current scope of utilisation (including specialist techniques), the potential barriers preventing its full adoption, and areas for future advancement and research.

Sanyar Video Laryngoscope Improved Time and First Pass Success of Tracheal Intubation in Intensive Care Unit in Compared to Direct Laryngoscopy

Background: Airway management and tracheal intubation in the ICU is a difficult procedure that may be concomitant with major complications. The purpose of this study was to evaluate the effect of the SANYAR ® video laryngoscope(S-VL) on laryngeal view and first Pass Success of tracheal Intubation compared with direct laryngoscopy.&#x0D; Methods: This comparative, prospective clinical study was conducted on 120 adult patients in a single-center, in a surgical ICU under the supervision of an anesthesiologist in a university hospital. Difficult airway predictors, glottic view, first Pass Success of tracheal Intubation and time of intubation were evaluated with Macintosh laryngoscopy (ML) or the SANYAR® Video Laryngoscope(S-VL).&#x0D; Results: Tracheal intubation was performed in 58 critically ill patients using ML and 62 patients using S-VL. According to Cormack and Lehane (C&amp;L) grading glottic visualization was more difficult using ML (41%, C&amp;L grade 3 and 4) compared with S-VL (13%, C&amp;L grade 3 and 4) p&lt;0.001. Intubation of trachea was more successful in the first attempt, in patients with at least one difficult airway predictor with a S-VL compared to ML (87% vs. 38%; P = 0.001), time of intubation was also shorter by using S-VL.&#x0D; Conclusion: Among critically ill patients in the intensive care unit, who require intubation, the SANYAR video laryngoscopy improved glottis view compared to the Macintosh direct laryngoscopy and first-pass orotracheal intubation rate especially in patients with potentially difficult airways.