Manual In-line Stabilization Research Articles

Comparison of C-MAC ® conventional blade, D-Blade ™ , and Macintosh laryngoscopes for endotracheal intubation in patients with simulated immobilization using manual in-line stabilization: A randomized trial.

A difficult airway is anticipated with cervical spine injuries (CSIs) as immobilization techniques such as manual in-line stabilization (MILS) are used, which distort the oro-pharyngeal-laryngeal axis. Video laryngoscopes (VLs) make difficult airway management easy, as they do not require axis alignment. The present study aimed to compare the total time taken by Macintosh laryngoscope (ML), conventional blade, and D-blade ™ of C-MAC ® VL in simulated CSI scenarios using MILS. Ninety patients were randomly allocated into three groups: Group M (ML), Group C (conventional blade of C-MAC ® ), and Group D (D-blade ™ of C-MAC ® ) with MILS applied before intubation. Primary outcome was the total time taken for successful intubation, while secondary outcomes were to assess Cormack-Lehane (CL) grade, number of attempts, hemodynamic response, and associated complications. Total time for intubation in Group C was 23.40 ± 7.06 sec compared to 35.27 ± 6.53 and 47.27 ± 2.53 sec in groups D and M, respectively ( P < 0.001). CL-grade I was observed in 15/30 (50%) in Group M, 25/30 (83.3%) in Group C, and 29/30 (96.7%) in Group D. Group M reported 7/30 (23.3%) failed intubations, while none were observed in other groups. Hemodynamic parameters were significantly higher at 3 and 5 min in Group M. Postoperative sore throat was recorded in 12/30 (40%) in Group M compared to 3/30 (10%) in groups C and D each ( P value 0.037). C-MAC ® VL requires less time for intubation, provides better glottic view, and has higher success, with better attenuation of hemodynamic response and fewer complications compared to ML.

Prehospital Cervical Spine (C-spine) Stabilization and Airway Management in a Trauma Patient: A Review.

Severe traumatic damage to the brain-to-body signaling bundle that results in bruising and a partial or total tear of the spinal cord is known as a spinal cord injury (SCI). SCI may develop at the time of an eventor after. It can also developwhile handling the patient andcan worsen during the transportation of the patient. So prehospital care is crucial to prevent or minimize SCI. Prehospital care involves examining the patient, immobilizing the cervical spine (C-spine), providing cardiovascular support (keeping the mean arterial blood pressure over 85 mmHg), and carefully managing the airway (possibly intubating the patient using manual in-line stabilization (MILS)).Methylprednisolone (MPS) and other pharmacological treatments have not been shown to offer clinically meaningful and essential benefits for people with SCI. The therapeutic use of MPS in patients with SCI in the prehospital context is no longer supported. Additionally, whether or not pharmaceutical drugs will be effective in therapeutic hypothermiais unknown. When performing endotracheal intubation on these patients, the potential for C-spine damage is always considered. During intubation, the MILSapproach significantly reduces C-spine movement. The MILS method, however, can potentially restrict mouth opening and result in subpar laryngoscopic vision. These issues can be handled using the recently developed video laryngoscope, such as Airtraq laryngoscope and AirWay Scope (AWS). Compared to a direct laryngoscope, the AWSand Airtraqlaryngoscope reduced the improvement of intubation conditions and the acceleration of tracheal intubation through the occiput-C1 and C2-C4 levels of the C-spineextension movement.

Endotracheal intubation and central venous catheter placement in lateral position in an emergency traumatic injury: an improvised attempt in crisis

Endotracheal intubation and central venous catheter (CVC) insertion are generally performed on the patient in the supine position. In traumatic cases, manual in-line stabilization and Sellick’s maneuver make airway management difficult. CVC insertion in the lateral position is not reported in the literature. A 30-year-old male with a history of falls from height presented with iron rods pierced into the right hand and right leg. The patient was intubated with manual in-line stabilization and Sellick’s maneuver in a lateral position. Due to the technical difficulty on the right side, CVC was inserted on the left side in a lateral position. Needle orientation was modified as per the position of the patient, and the left arm was pulled during the CVC insertion. The most experienced anesthesiologists should attempt for the best outcome. Wherever available, CVC should be inserted under ultrasonic guidance. With the landmark technique, the three-dimensional orientation of the anatomy should be kept in mind while attempting CVC insertion in an abnormal position.

Direct versus indirect epiglottis elevation in cervical spine movement during videolaryngoscopic intubation under manual in-line stabilization: a randomized controlled trial

BackgroundDuring videolaryngoscopic intubation, direct epiglottis elevation provides a higher percentage of glottic opening score than indirect epiglottis elevation. In this randomized controlled trial, we compared cervical spine movement during videolaryngoscopic intubation under manual in-line stabilization between the two glottis exposure methods.MethodsVideolaryngoscopic intubation under manual in-line stabilization was performed using C-MAC® D-blade: direct (n = 51) and indirect (n = 51) epiglottis elevation groups. The percentage of glottic opening score was set equally at 50% during videolaryngoscopic intubation in both groups. The primary outcome measure was cervical spine movement during videolaryngoscopic intubation at the occiput–C1, C1–C2, and C2–C5. The secondary outcome measures included intubation performance (intubation success rate and intubation time).ResultsCervical spine movement during videolaryngoscopic intubation was significantly smaller at the occiput–C1 in the direct epiglottis elevation group than in the indirect epiglottis elevation group (mean [standard deviation] 3.9 [4.0] vs. 5.8 [3.4] °, P = 0.011), whereas it was not significantly different at the C1–C2 and C2–C5 between the two groups. All intubations were successful on the first attempt, achieving a percentage of glottic opening score of 50% in both groups. Intubation time was longer in the direct epiglottis elevation group (median [interquartile range] 29.0 [24.0–35.0] vs. 22.0 [18.0–27.0] s, P < 0.001).ConclusionsWhen performing videolaryngoscopic intubation under manual in-line stabilization, direct epiglottis elevation can be more beneficial than indirect epiglottis elevation in reducing cervical spine movement during videolaryngoscopic intubation at the occiput–C1.Trial registrationClinical Research Information Service (number: KCT0006239, date: 10/06/2021).

Comparison of Tracheal Intubation Using King Vision (Non-channeled Blade) and Tuoren Video Laryngoscopes in Patients With Cervical Spine Immobilization by Manual In-Line Stabilization: A Randomized Clinical Trial.

Glottic visualization on cervical immobilization with manual in-line stabilization (MILS) might be challenging in individuals with cervical spine injuries. We compared non-channeled King Vision video laryngoscope (VL) (Ambu GmbH, Bad Nauheim, Germany) with Tuoren video laryngoscope (Henan Tuoren Medical Device, Zhengzhou, China) for endotracheal intubation in patients with cervical spine immobilization. A total of 124 patients undergoing elective surgery under general anesthesia were included in this study. After induction of general anesthesia, patients were randomized into two groups (62 each): group K (non-channeled blade of King Vision video laryngoscope) and group T (Tuoren video laryngoscope). Cervical spine immobilization was achieved with manual in-line stabilization. The success of the first pass intubation, the time required to intubate, glottic visualization, and intubation difficulty score (IDS) were recorded. The first-attempt success rate of intubation was 95.2% (59 out of 62 patients) in group K and 90.3% (56 out of 62 patients) in group T, which were comparable. The mean glottic visualization time was significantly less with group T (12.74 ± 6.32 seconds) compared to group K (17.92 ± 4.24 seconds). Intubation time was significantly faster with group K (18.79 ± 5.857 seconds) compared to group T (27.21 ± 8.514 seconds). Both video laryngoscopes provided good grades of glottic visualization. We conclude that the performance of the Tuoren video laryngoscope is similar to the King Vision video laryngoscope in terms of first-attempt intubation success rate and glottic visualization score in patients with cervical spine immobilization by manual in-line stabilization. Although glottic visualization time was shorter with Tuoren VL, we could achieve faster intubationwith King Vision VL.

Comparison of airway maneuvers (manual in line stabilization, modified jaw thrust, and conventional maneuver) for orotracheal intubation during direct laryngoscopy

Background: During performing orotracheal intubation with direct laryngoscopy adequate laryngeal visualization depends on proper airway maneuvers. There are different types of airway maneuvers. Aims and Objectives: This study aimed to compare airway maneuvers; manual in line stabilization (MILS), jaw thrust, and conventional maneuver to assess better laryngeal visualization and ease of intubation among them and associated complications. Materials and Methods: This observational study was conducted in 90 adult patients. Patients divided into three groups. Laryngoscopy and intubation in Group M were done in MILS and in group J jaw thrust. In Group C, as conventional maneuver performed. Laryngeal visualization assessed using modified Cormack–Lehane grading and ease of intubation assessed using intubation time, number of attempts between these three groups. The data were compared using ANOVA test, Chi-square test. Results: While comparing between these groups better laryngeal visualization seen in jaw thrust group, while the MILS maneuver worsen the view. Conclusion: The present study concluded that jaw thrust maneuver improved the laryngeal visualization and conventional maneuver made intubation faster and easy.

Comparison between stylet and bougie with the C-MAC D-blade in cervical simulated immobility. A prospective randomized controlled trial

Introduction: The C-MAC D-blade was designed for difficult airway intubation scenarios. To facilitate easier and faster endotracheal intubation in the laryngoscopy paradox, an introducer is preferred. Hence, we decided to conduct a study to compare the 60˚ angled C-MAC stylet and the gum elastic bougie as aids to intubation while using the C-MAC D-blade laryngoscope in a simulated difficult airway setting. Objective: To compare the ease of oral intubation with the use of the C-MAC stylet (60˚ angled stylet) versus intubation performed over a bougie inserted using the C-MAC D-blade guidance in patients with simulated restricted cervical mobility. Methods: Prospective, randomized controlled single-center study. Intubation using the C-MAC D-blade laryngoscope was performed in 48 surgical patients randomly assigned to 2 groups of 24 each: Stylet group, Group S (using 60˚ angled stylet) and Bougie group, Group B (using bougie) after providing manual in-line stabilization to restrict cervical mobility. The Mann-Whitney U test and the Chi square test were used as applicable. Results: The use of stylet resulted in easier (Group S 75% vs. Group B 16.7%) and faster (Group S 26.83 ± 8.61s vs. Group B 47.18 ± 16.46s) intubation with fewer attempts compared to group B. Both groups experienced a similar hemodynamic stress response to intubation. Conclusions: The 60˚ angled C-MAC Stylet is a more effective and time-saving intubation aid with C-MAC D-blade compared to bougie.

Comparison of the McGRATHTM Video Laryngoscope and Macintosh Laryngoscope for Orotracheal Intubation in a Simulated Difficult Airway Scenario: An Open-Label, Randomized Clinical Trial

Background and Objectives: Difficult intubation, which may be encountered unexpectedly during anesthesia, can increase patients' morbidity and mortality. The McGRATH video laryngoscope is known to provide improved laryngeal visibility in patients with difficult or normal airways. The purpose of this study was to evaluate the efficacy of the McGRATH video laryngoscope for orotracheal intubation compared with that of conventional Macintosh laryngoscopes in simulated difficult airway scenarios. Materials and Methods: In this randomized controlled trial, patients who were scheduled for surgery under general anesthesia requiring orotracheal intubation were assigned to the Macintosh laryngoscope (n = 50) or McGRATH video laryngoscope (n = 45) groups. In this study, to create a simulated difficult airway condition, the subjects performed manual in-line stabilization and applied a soft cervical collar. The primary outcome was the rate of successful intubation within 30 s. The time required for an intubation, glottis grade, intubation difficulty scale (IDS score), the subjective ease of intubation, and optimal external laryngeal manipulation (OLEM) were evaluated. In addition, complications caused by each blade were investigated. Results: The intubation success rate within 30 s was not significantly different between the two groups (44 (88.0%) vs. 36 (80.0%), p = 0.286). The glottic grade was better in the McGRATH group than in the Macintosh group (p = 0.029), but neither the intubation time (26.3 ± 8.2 s vs. 24.2 ± 5.0 s, p = 0.134) nor the rates of oral bleeding (2 (4.0%) vs. 0 (0.0%)) and tooth injury (0 (0.0%) vs. 1 (2.2%)) were significantly different between the two groups. Conclusions: The use of the McGRATH video laryngoscope did not improve the intubation success rate or shorten the intubation time. However, the McGRATH video laryngoscope provided a better glottis view than the conventional Macintosh laryngoscope in patients with a simulated difficult airway.

Anesthetic considerations in Hirayama disease: Primum non noncere.

Dear Editor, Hirayama disease is a sporadic, self-limiting juvenile muscular atrophy which affects the muscles of the arm of people of the Asian population in the third decade of life.[1] In the past 35 years, only 279 cases have been reported in India.[2] A 40-year-old male presented with complaints of weakness and pain in the right upper limb with grade 2/5 power and wasting of thenar, hypothenar, interossei muscles, wrist flexors, and extensors with the sparing of the brachioradialis muscle. It is called oblique amyotrophy.[3] The Babinski sign was positive. There was no history of involuntary movements, trauma, exaggeration of symptoms in winter, allergy to peanuts, and sulpha-containing drugs. There was no cranial nerve, sensory, bulbar, bladder, or bowel involvement. The Magnetic Resonance Imaging (MRI) [Figure 1] showed forward displacement of the posterior subdural sac on the flexion of the neck with prominent epidural space. Electromyographic nerve conduction velocity (EMG-NCV) findings showed partial denervation in the upper limb muscles. The thyroid function tests, creatinine kinase, and serum potassium levels were normal.Figure 1: MRI Hirayama diseaseAnticholinergic intravenous glycopyrrolate 0.2 mg was given as an anti-sialagogue. Following an intravenous propofol 1.5 mg/kg induction, we preferred rocuronium bromide 0.9 mg/kg for the neuromuscular blockade, for its rapid onset of action. Injection atracurium was avoided as it has a propensity to raise the ImmunoglobulinE (IGE) levels which precipitate atopic myelitis in the Hirayama disease.[4] Also, in patients with denervation because of spinal cord lesions, an increased number of peri-junctional nicotinic acetylcholine receptors on skeletal muscle can cause hyperkalemia after suxamethonium chloride. Laryngoscopy was performed with manual inline stabilization of the spine (MILS) and a LaerdalR Philadelphia hard cervical collar on, using a McCoy laryngoscope blade and the patient was intubated with a size 8.0 cuffed flexo-metallic tube. The immobilization aims to protect patients with an unstable cervical spine from secondary cervical spine injury induced by accidental movement of the spine.[5] Proning was done by proper precautions, adequate eye care, and padding of pressure points were done. Auto-compression stockings were applied on the lower limbs for deep venous thrombosis (DVT) prophylaxis. Sevoflurane was given to maintain Bispectral Index (BIS)-guided adequate depth of anesthesia. These patients may have a less physiological reserve to tolerate hypotension-induced ischemia and require higher arterial pressures to maintain spinal autoregulation.[5] Injection phenylephrine infusion 1 mg/cc was kept ready. Train Of Four (TOF) monitoring was done intraoperatively and readings were taken before reversal and extubation. Hirayama disease is a sporadic focal degenerative motor neuron disease affecting the cervical cord when the neck is in flexion. Repeated compression changes make the anterior horn cells prone to arterial or venous ischemic injury which causes increased intramedullary pressure and micro-circulatory disturbance.[3] This is in line with the Poisson effect which dictates that if a column of fixed volume is compressed, its cross-sectional area will increase. Conversely, if it is stretched, the cross-sectional area will decrease, which is based on the Chinese finger trap model [Figure 2]. The basic principle is to keep the neck in extension.Figure 2: The Chinese finger trap modelRational airway management, appropriate choice of muscle relaxants in motor neuron diseases, and the use of intraoperative neuromuscular monitoring helped in the optimal, safe, and effective anesthetic management. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given hid consent for his images and other clinical information to be reported in the journal. The patients should understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Airway management in patients with cervical spine injury with a C-MAC Videolaryngoscope : A case report

Patients with cervical spine injuries pose a significant challenge to an anesthesiologist. The airway management of these patients involves movements of the cervical spine that may worsen pre-existing injury resulting in poor post-operative neurological outcomes. We present a case report of a patient with cervical spine injury posted for spinal fusion under general anaesthesia. Intubation of the patient was done with C-MAC videolaryngoscope (VDL) with manual inline stabilisation (MILS) after induction with intravenous anaesthetic agents. The perioperative haemodynamic parameters were found to be stable with statistically insignificant deviation from the baseline values. All patients were examined post operatively with no post-operative adverse events including bronchospasm, dysphagia, aspiration or any neurological deficits. We concluded that VDL assisted intubation has several advantages in the care of these patients.

Comparison of the C-MACTM ‘D’ blade with AirTraq® for endotracheal intubation in patients with simulated limitation of cervical movements

Background: Direct laryngoscopy and tracheal intubation with manual in-line stabilisation is the standard practice for trauma victims while securing the airway when cervical injury/instability is suspected. The use of videolaryngoscopes eliminates the need to align the three axes, avoids movement at cervical joints, allows viewing around the corner and improves glottic view. Aim: Comparison of C-MACTM‘D’Blade and AirTraq® for endotracheal intubation in patients with simulated limitation of cervical movements. Methodology: This was a prospective, randomised study conducted on 52 consenting patients requiring intubation. They were assigned to undergo intubation using C-MACTM‘D’Blade (n=26) or AirTraq® (n=26) by an anaesthesiologist experienced in the use of both laryngoscopes while MILS was provided. Results: Laryngoscopic view was similar in the two groups: grade 1 in 16 (61.5%) and 21 patients (81.8%) in the ‘D’blade and AirTraq® groups respectively with the remaining having a grade 2 view. The median time for laryngoscopy was less (13 s) in the ‘D’ blade compared to AirTraq® group (19.6 s) and was statistically significant (p= 0.036) but clinically insignificant. The intubation time was comparable (p=0.094). Most patients in both groups were intubated successfully in the first attempt. Requirement of airway manipulation to optimise view, postoperative sore throat and blood on the endotracheal tube was comparable. Good overall satisfaction score was obtained in bothgroups. Conclusion: Both C-MACTM ‘D’Blade and AirTraq® when used for intubation in patients with simulated limitation of cervical movements provide similar videolaryngoscopic view, time for laryngoscopy and intubation, and overall satisfaction score.

A comparative study of the C-MAC D-blade videolaryngoscope and McCoy laryngoscope for oro-tracheal intubation with manual in-line stabilization of neck in patients undergoing cervical spine surgery.

Airway management in cervical spine injury patients requires manual in-line stabilization (MILS) of the neck to avoid exacerbation of cord injury, which impedes visualization of glottis during laryngoscopy. Specially designed blades such as McCoy and C-MAC D-blades can improve laryngoscopic view in such patients. This study was performed to compare the efficacy of C-MAC D-blades and the McCoy laryngoscope for oro-tracheal intubation using MILS in patients undergoing cervical spine surgery. This randomized, prospective study was performed in 60 adult patients of American Society of Anesthesiologists grade I-III, either sex, 18 to 60 years of age undergoing elective cervical spine surgery. Patients were randomly categorized into two groups, group D and group M. Intubation was performed using a C-MAC D-blade videolaryngoscope in group D and a McCoy laryngoscope in group M using MILS. The intubation difficulty scale (IDS) score, laryngoscopy and intubation times, percentage of glottic opening (POGO) score, Cormack Lehane (CL) grading with and without external laryngeal pressure (ELP), need for bougie or change of blade or operator, and change in hemodynamics following intubation were recorded. Group D showed lower mean IDS scores than group M (P value < 0.0001). There were statistically significant differences found in duration of laryngoscopy (group D < group M), CL grading without ELP (group D: CL-1,2a >CL-2b, 3; group M: CL-1,2a <CL-2b, 3), mean POGO scores without ELP (group D > group M), need for ELP and lifting force (group D < group M), and hemodynamic responses after intubation (group D < group M). A C-MAC D-blade videolaryngoscope provides better and rapid visualization of glottis with less intubation difficulties than a McCoy laryngoscope during intubation using MILS in patients with cervical spine injury.

Airway management in patients with suspected or confirmed traumatic spinal cord injury: a narrative review of current evidence.

SummaryAround 1 million people sustain a spinal cord injury each year, which can have significant psychosocial, physical and socio‐economic consequences for patients, their families and society. The aim of this review is to provide clinicians with a summary of recent studies of direct relevance to the airway management of patients with confirmed or suspected traumatic spinal cord injury to promote best clinical practice. All airway interventions are associated with some degree of movement of the cervical spine; in general, these are very small and whether these are clinically significant in terms of impingement of the spinal cord is unclear. Manual in‐line stabilisation does not effectively immobilise the cervical spine and increases the likelihood of difficult and failed tracheal intubation. There is no clear evidence of benefit of awake tracheal intubation techniques in terms of prevention of secondary spinal cord injury. Videolaryngoscopy appears to cause a similar degree of cervical spine displacement as flexible bronchoscope‐guided tracheal intubation and is an appropriate alternative approach. Direct laryngoscopy does cause a slightly greater degree of cervical spinal movement during tracheal intubation than videolaryngoscopy, but this does not appear to increase the risk of spinal cord compression. The risk of spinal cord injury during tracheal intubation appears to be minimal even in the presence of gross cervical spine instability. Depending on the clinical situation, practitioners should choose the tracheal intubation technique with which they are most proficient and that is most likely to minimise cervical spine movement.

Comparison of video-stylet and conventional laryngoscope for endotracheal intubation in adults with cervical spine immobilization: A PRISMA-compliant meta-analysis.

Background:Although minimization of cervical spine motion by using a neck collar or manual in-line stabilization is recommended for urgent tracheal intubation (TI) in patients with known or suspected cervical spine injury (CSI), it may worsen glottic visualization. The overall performance of video-stylets during TI in patients with neck immobilization remains unclear. The current meta-analysis aimed at comparing the intubation outcomes of different video-stylets with those of conventional laryngoscopes in patients with cervical immobilization.Method:The databases of Embase, Medline, and the Cochrane Central Register of Controlled Trials were searched from inception to June 2021 to identify trials comparing intubation outcomes between video-stylets and conventional laryngoscopes. The primary outcome was first-pass success rate, while secondary outcomes included overall success rate, time to intubation, the risk of intubation-associated sore throat, or tissue damage.Results:Five randomized controlled trials published between 2007 and 2013 involving 487 participants, all in an operating room setting, were analyzed. The video-stylets investigated included Bonfils intubation fiberscope, Levitan FPS Scope, and Shikani optical stylet. There was no difference in first-pass success rate (risk ratio [RR] =1.08, 95% confidence interval [CI]: 0.89–1.31, P = .46], overall success rate (RR = 1.06, 95% CI: 0.93–1.22, P = .4), intubation time [mean difference = 4.53 seconds, 95% CI: –8.45 to 17.51, P = .49), and risk of tissue damage (RR = 0.46, 95% CI: 0.16–1.3, P = .14) between the 2 groups. The risk of sore throat was lower with video-stylets compared to that with laryngoscopes (RR = 0.45, 95% CI: 0.23–0.9, P = .02).Conclusion:Our results did not support the use of video-stylets as the first choice for patients with neck immobilization. Further studies are required to verify the efficacy of video-stylets in the nonoperating room setting.

Intubation during spinal motion restriction using the LuboTM cervical collar - a manikin simulation study.

IntroductionThe LuboTM collar is a cervical motion restriction device featuring a unique external jaw-thrust mechanism designed to provide non-invasive airway patency. In addition, tracheal intubation is facilitated by releasing an anterior chin strap; this allows better mouth opening than the previous generation of semi-rigid cervical collars. This study aimed to compare tracheal intubation using the LuboTM collar combined with manual in-line stabilization (MILS) to intubation with MILS alone. The primary outcome was the time to successful intubation. Secondary outcomes compared intubation success rate, Cormack-Lehane grade, ease of intubation and dental trauma.MethodsA randomized, cross-over, equivalence study was performed. Eighty full-time physician anaesthesia providers were recruited. Participants performed tracheal intubation using direct laryngoscopy on a manikin under two different scenarios: with the LuboTM collar and MILS applied, and with MILS and no cervical collar. The time to successful intubation was measured and compared using two-one-sided and paired t-tests.ResultsIntubation times fell well within the a priori equivalence limits of 10 seconds, with a mean difference (95% CI) of 0.52 seconds (-1.30 to 2.56). There was no significant difference in intubation time with the LuboTM collar (mean [SD] 19.2 [4.5] seconds) compared to the MILS alone group (19.7 [5.2] seconds). The overall success rate was 98.7% in the Lubo group and 100% in the MILS group. Adequate laryngoscopy views (Cormack-Lehane grades I to IIb) were equivalent between groups (Lubo 92.5% versus MILS alone 93.7%).ConclusionIn this manikin-based study, the time to intubation with the LuboTM collar and MILS applied was equivalent to time to intubation with MILS alone, with similar intubating conditions. Thus, the LuboTM collar and MILS may simplify airway management by reducing the number of steps required to perform intubation in patients requiring cervical motion restriction.

Removal of the cervical collar from alpine rescue protocols? A biomechanical non-inferiority trial in real-life mountain conditions

BackgroundAlpine skiing rescues are challenging because of the mountainous environment and risks of cervical spine motion (CSM) induced during victims’ extrications (EXs) and downhill evacuations (DEs). The benefits of applying a cervical collar (CC) over manual in-line stabilization without CC (MILS) in terms of spinal motion restriction during simulated alpine rescues are undocumented. Our hypothesis was that CSM recorded using MILS alone is non-inferior to CSM recorded with a CC according to a 10 degrees margin.MethodsA total of 32 alpine extrications and 4 downhill evacuations on different slope conditions were performed using a high fidelity mannequin designed with a motion sensors instrumented cervical spine. The primary outcome was the peak extrication 3D excursion angle (Peak 3D θEX,) of the mannequin’s head. The secondary objectives were to describe the time to extrication completion (tEX) and to highlight which extrication manipulation is more likely to induce CSM.ResultsThe median Peak 3D θEX recorded during flat terrain extrications using CC was 10.77° (95% CI 7.31°–16.45°) compared to 13.06° (95% CI 10.20°–30.36°) using MILS, and 16.09° (95% CI 9.07°–37.43°) for CC versus 16.65° (95% CI 13.80°–23.40°) using MILS on a steep slope. Peak 3D θEX with CC or using MILS during extrications were equivalent according to a 10 degrees non-inferiority hypothesis testing (p < 0.05). Time to extrication completion (tEX) was significantly reduced using MILS without CC on a flat terrain with a median duration of 237,3 s (95% CI 197.8 s, 272.2 s) compared to 358.7 s (95% CI 324.1 s, 472.4 s). During downhill evacuations, CSM with and without CC across all terrain conditions were negligible (< 5°). When CC is used; its installation manipulation induces the highest CSM. When EXs are done using MILS without CC, the logroll initiation is the manipulation inducing the highest risk of CSM.ConclusionFor experienced ski patrollers, the biomechanical benefits of spinal motion restriction provided by CC over MILS during alpine skiing rescues appear to be marginal and CC use negatively affects rescue time.

Comparison of Macintosh, McCoy, Truview EVO2, and King Vision Laryngoscopes for Intubation in Patients with Immobilized Cervical Spine

Abstract Background: Immobilization of the neck in cervical spine injury patients can lead to misalignment of the oral, pharyngeal, and laryngeal axis, thereby making intubation more difficult. The principal aim of our study was to compare the efficacy of King Vision, Truview Evo2, and McCoy with Macintosh laryngoscope in patients getting intubated with cervical spine immobilized using manual inline stabilization. Materials and Methods: This was a randomized, controlled trial of 160 patients who were randomized to undergo surgery under general anesthesia with endotracheal intubation. We equally divided the subjects into using either Macintosh, McCoy, Truview Evo2, and King Vision laryngoscopes to facilitate intubation. We evaluated the intubation difficulty using the Intubation Difficulty Score (IDS) and Cormack–Lehane grading. Results: King Vision, Truview Evo2, and McCoy reduced the IDS as compared to Macintosh (P &lt; 0.001). King Vision showed a first-attempt success rate of 100%. Cormack and Lehane's glottic views were best with King Vision followed by Truview Evo2 and there was much less need for external manipulation as compared to McCoy and Macintosh. Time taken for intubation was least with McCoy blade (22.9 ± 7.2 s, P &lt; 0.001). Conclusion: The use of both King Vision and Truview Evo2 significantly resulted in a decreased the IDS and improved Cormack–Lehane grading as compared to Macintosh and McCoy.

Success Rate on Endotracheal Intubation with Prone versus Kneeling Position in Mannequin Model with Limitation of Neck Movement: A Cross Over Study.

PurposeEndotracheal intubation is a lifesaving procedure for airway management but is more complex when performed in patients lying on the ground and requiring cervical spine immobilization. This study aims to compare the optimal technique between prone and kneeling positions in increasing intubation success rate on these prehospital trauma patients.Patients and MethodsThis study was an experimental study on a mannequin. Paramedic students performed intubation on the supine mannequin, which was applied with a rigid cervical collar and manual in-line stabilization. The participants were randomly assigned to intubate in a prone or kneeling position as the first method, then perform another method seven days later. Study outcomes include the percentage of successful intubation, time to perform intubation successfully, and Cormack and Lehane’s classification of laryngeal view.ResultsThirty-nine participants were enrolled in this study; 22 were male (56.41%). The mean age, weight, and height were 23.15 ± 4.75 years, 67.38 ± 17.39 kg, and 167.36 ± 8.70 cm., respectively. The percentage of successful intubation in prone (37 [94.90%]) was higher than kneeling position (35 [89.74%]), but there was no statistically significant (p-value = 0.675). Time to intubation successfully, the number of attempts, and Cormack & Lehane's laryngeal view classification were not significantly different between prone and kneeling groups (p-value = 0.808, 0.814, and 0.948, respectively).ConclusionIntubation with the prone or kneeling position on a mannequin, lying on the ground with cervical spine immobilization, has no statistical difference. Both intubation approaches appear to be effective in successful and rapid intubation, proper glottic visualization and low attempts.

Airway hitches and management in Maroteaux-Lamy syndrome.

Dear Editor, Maroteaux-Lamy Syndrome (mucopolysaccharidosis type VI [MPS VI]) is caused by deficiency of N-acetylgalactosamine-4-sulfatase resulting in accumulation of dermatan sulfate which evokes the varied spectra of clinical symptoms.[1] Dysmorphic facial features with multi-systemic involvement pose a formidable challenge to anesthetists. We present a case of an 8-year-old female child with progressive bilateral flexion deformity of fingers, mouth breathing and snoring. She was posted for cervical (C1-C2) fixation surgery. Child had coarse facial features, macrocephaly (head circumference: 60 cm), macroglossia, short neck (thyromental distance: 4.5 cm, sternomental distance: 7 cm) and restricted neck mobility [Figure 1a]. Our plan A was C-MAC videolaryngoscopic (C-MAC®VL)-guided intubation with backup plans of fiber-optic bronchoscope (FOB)-guided intubation, retrograde intubation, and front of neck access as plans B, C, and D respectively. Consent of the mother was obtained. ASA standard monitors were attached. Continuous high flow nasal cannula (HFNC) oxygen therapy was started [Figure 1b]. Fentanyl 2mcg/kg (IV) was given and inhalational induction with sevoflurane was started. There was difficulty in mask ventilation even after oral airway insertion. So, immediate insertion of supreme laryngeal mask airway (LMA) size-2 enabled adequate ventilation [Figure 2a]. Injection rocuronium 1 mg/kg (IV) was administered. LMA was removed and endotracheal intubation was performed using C-MAC®VL at second attempt using bougie. Apneic oxygenation with HFNC and manual in-line stabilization was ensured until endotracheal intubation was achieved. When the patient was turned from prone to supine position after surgery, we noticed edema of the lips and tongue [Figure 2b]. Videolaryngoscopy revealed edema of posterior commissure which resolved with intravenous steroids and then extubated 24 hours later in ICU.Figure 1: (a) shows facial and airway profile in this child with MPS. (b) shows continuous HFNC therapyFigure 2: (a) Supreme LMA inserted to facilitate ventilation before endotracheal intubation. (b) Edematous tongue and lips noted when patient turned supine after surgeryMaroteaux–Lamy syndrome is a type of mucopolysaccharidosis characterized by learning difficulties, mental retardation, coarse facial features, frontal bossing, depressed nasal bridge, macroglossia, adeno-tonsillar hypertrophy, narrowed airway, short, stiff neck and temporomandibular joints leading to difficult airway.[2,3] Multi-systemic involvement includes obstructive or, restrictive lung disease, valvular heart disease and cardiomyopathy. Instability of the atlantoaxial joint requires special care during intubation to prevent further compression of the cervical spinal cord.[4] Difficulty in maintaining adequate ventilation may be due to obstructive and restrictive lung disease. Intraoperative hemodynamic instability may occur due to underlying cardiac disease. Prone position can further aggravate existing airway narrowing as it can lead to airway edema which may pose difficulty during extubation. In our case, we chose inhalational induction over intravenous induction as it was anticipated difficult airway. We could overcome the difficulty of mask ventilation by expeditious insertion of LMA. C-MAC®VL-guided intubation was chosen over the fiber-optic technique as it provides fixed wide view of the glottis that aids in quick recognition of airway landmarks.[5] FOB-guided intubation would be difficult as the patient had poor comprehension and, airway collapse leads to difficulty in maneuvering and advancement. HFNC oxygen therapy prevented desaturation. Thus, from this case, we infer that in a child with mucopolysaccharidosis, inhalational induction, ventilation with LMA followed by intubation with C-Mac videolaryngoscope would be a logical method of airway management. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Laryngoscopic View after Application of Manual In-Line Stabilization - A Comparison with Early Morning Sniffing Position in the Same Patient.

Background:The application of manual in-line stabilization (MILS) for minimizing spinal cord injury is known to increase difficulty in airway management.Aim:The study aims to assess the change in Modified Cormack–Lehane (CL) laryngoscopic view with the application of MILS from the early morning sniffing position (EMSP) in adult patients.Setting and Design:This was a prospective, interventional, self-controlled study conducted on 220 patients aged 18–65 years, belonging to the American Society of Anesthesiologists Physical Status Class I or II, having a normal airway, and scheduled for elective surgery under general anesthesia.Materials and Methods:After inducing general anesthesia, MILS was applied to the patient's neck, and a Modified CL view of the vocal cords was recorded under direct laryngoscopy. The view was again noted after applying backward-upward-rightward pressure (BURP). MILS and BURP were released. The view was obtained again with and without BURP in EMSP.Statistical Analysis:Normality of data was tested by Kolmogorov–Smirnov test. Wilcoxon ranked-sum test for quantitative variables and Chi-square test for qualitative variables were used.Results:On application of MILS, the majority of patients had Modified CL Grade 3a (121 patients) and 3b (53 patients) views. The majority of patients had Modified CL Grade 1 (114 patients) and 2a (71 patients) views on placing in EMSP. These findings were statistically significant (P < 0.0001). Consequent to the placement of BURP upon MILS, patients with lower CL Grade views (2b: 101 patients) were significantly higher (P < 0.0001) in comparison with MILS alone.Conclusion:In patients with a normal airway, MILS leads to a significantly greater incidence of higher grades of laryngoscopic views in comparison to EMSP. Use of BURP after MILS causes significantly less incidence of higher grades of laryngoscopic view when compared with MILS alone. All patients requiring MILS should be considered to be a difficult airway, and hence, preparation should be done accordingly.