Optimal External Laryngeal Manipulation Research Articles

Video Laryngoscopy Versus Direct Laryngoscopy in Novices: A Randomized Clinical Trial

Intubating the trachea is a challenging task, especially for novice intubators. Successful intubation, in the shortest possible time, prevents hypoxia and hemodynamic disturbances. During the last few decades, video laryngoscopy has proven to be a helpful tool for intubating patients successfully, especially in difficult cases. However, novices must be proficient with a video laryngoscopy. It is not entirely clear which method, direct laryngoscopy or video laryngoscopy, is more successful for tracheal intubation in individuals who have recently started their airway management training. In this study, we aim to investigate this issue. 150 patients were randomly assigned to either direct laryngoscopy or video laryngoscopy by first-year anesthesia assistants. Intubation time, intubation success rate, Cormack-Lehane score, and instances of using the Optimal external laryngeal manipulation (OELM) maneuver, were recorded. The rate of successful intubation was higher in the direct laryngoscopy group, and the time taken was less. The direct laryngoscopy provided a better view of the glottis than the video laryngoscopy, although this difference was not statistically significant. Direct laryngoscopy resulted in a higher frequency of OELM. Based on our study, the success rate and speed of intubation in novices were higher with direct laryngoscopy compared to video laryngoscopy.

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.

A randomized comparative evaluation of C-MAC video-laryngoscope with Miller laryngoscope for neonatal endotracheal intubation.

An efficient neonatal airway management is peculiarly challenging even in the most experienced hands. Considering the recent interest in assessing the performance of various video-laryngoscopes (VL) in pediatric cohort, the prospective randomized study was contemplated to stage a comparative evaluation of C-MAC with Miller laryngoscope for neonatal endotracheal intubation. 150 neonates were randomized to undergo intubation with either the C-MAC VL (n = 75) or the Miller laryngoscope (n = 75) performed by an experienced anesthesiologist in a tertiary care perioperative setting. The percentage of glottic opening (POGO), time to best glottic view (TTBGV), time to intubation (TTI), number of attempts, optimal external laryngeal manipulation (OELM) employed, and the complications were assessed and compared between the two groups. C-MAC group demonstrated a significantly higher POGO, compared to the Miller group (88 ± 26.7%;76.8 ± 32.1%, respectively, P = 0.022). TTBGV was significantly lower in the C-MAC (7.7 ± 0.1s) group as opposed to the Miller group (11.3 ± 1.1s). The C-MAC group displayed higher TTI values compared to the Miller group (25.4 ± 1.6s; 19.7 ± 1.2s, respectively, P < 0.01). The first-attempt intubation success rate and the number of attempts were comparable in both the groups. OELM was required in 24% of the patients in the Miller group as opposed to 10.7% in the C-MAC group (P = 0.031). Higher patient percentage in the C-MAC group required the need of stylet for assisting a successful intubation, although the difference between the two groups was not statistically significant. Despite an improved view of the glottis, the TTI was higher for C-MAC compared to direct laryngoscopy with a comparable first-attempt success rate in the two techniques.

Efficacy and safety of videolaryngoscopy versus direct laryngoscopy in paediatric intubation: A meta-analysis of 27 randomized controlled trials

ObjectiveAnatomical and physiological differences in paediatric and adult airways make intubation of paediatric patients a challenge. This study aimed to compare the efficacy and safety of video laryngoscopy (VL) to direct laryngoscopy (DL) on intubation outcomes in paediatric patients. DesignSystematic review and meta-analysis. SettingOperating room. PatientsPaediatric patients who needed tracheal intubation. InterventionVideo laryngoscopy or direct laryngoscopy. MeasurementsElectronic searches in PubMed, Embase, and the Cochrane Library were performed to identify relevant randomized controlled trials published through January 2020. Outcomes included time to intubate, intubation failure at first attempt, Cormack-Lehane laryngeal view grade, intubation difficulty scale (IDS), percentage of glottic opening score (POGO), optimal external laryngeal manipulation (OLEM), and complications. Relative risks and weighted mean difference (WMD), with 95% CI, were employed to calculate summary results using a random-effects model. Main resultsOverall, 27 trials including 2461 paediatric patients were analysed. Children with video laryngoscopy intubation required longer time to intubate than direct laryngoscopy intubation (WMD 3.41, 95% CI: 1.29–5.53, P = 0.002), whereas infants receiving video laryngoscopy and direct laryngoscopy intubation experienced similar time to intubate (WMD 1.72, 95% CI: −1.09-4.54, P = 0.230). No significant differences were observed on intubation failure at first attempt between video laryngoscopy and direct laryngoscopy intubations in children and infants, respectively. Video laryngoscopy improved the POGO and intubation trauma but not Cormack-Lehane laryngeal view grade, IDS, external laryngeal manipulation, hoarseness, or oxygen desaturation. ConclusionsCompared with direct laryngoscopy intubation, there were no benefits for paediatric patients with video laryngoscopy on time to intubate and failure at first attempt, but there were benefits with regard to POGO and intubation trauma.

Midline versus paraglossal laryngoscopic approach using the Miller blade in small children: A randomised, controlled, cross-over study

Background: Airway management in children is different from that of adults and needs special consideration. Laryngoscopy in children with the Miller straight blade can be performed via midline (MID) or paraglossal (PGL) approach. This study aimed to find out whether there was any advantage of one approach over the other in small children. Patients and Methods: After obtaining parental consent and approval from the Institutional Ethical Committee, this randomised, controlled, cross-over study was conducted in 110 children aged 2–24 months belonging to the American Society of Anesthesiologists Physical Status I or II. Children scheduled for elective surgeries under general anaesthesia were allocated randomly into one of the following two groups: A (PGL/MID) or B (MID/PGL) with 55 patients in each group. Following induction of anaesthesia and neuromuscular blockade, laryngoscopy was performed in a cross-over manner with either the PGL or MID approach first. The tip of the blade was placed at the vallecula. Intubation was performed following the second laryngoscopy. Glottic views with and without optimal external laryngeal manipulation (OELM) and ease of intubation were observed. Data were analysed, and P

Comparative evaluation of conventional to left molar and right molar laryngoscopy and endotracheal intubation

Background: Difficulty in visualizing the glottis may cause difficulty, even failure in endotracheal intubation leading to catastrophes. Difficult laryngoscopy is frequently overcome by using molar approach for laryngoscopy combined with optimal external laryngeal manipulation (OELM). The present study was planned to compare conventional midline approach of laryngoscopy to left molar and right molar approach of laryngoccopy (using Macintosh blade) for endotracheal intubation Material and Methods: This prospective randomized double blind controlled study was conducted on 120 patients of 18-60 years age, belonging to ASA grade I and II of either sex, posted for elective surgery under general endotracheal anaesthesia. Depending on the approach of laryngoscopy used, the patients were randomly divided into three groups of 40 each into Group M (midline approach), Group L (left molar approach) and Group R (right molar approach). Predictors of difficult intubation (Modified Mallampati grading, Thyromental distance, abnormal Dentition) and their association with unsuccessful intubation, Cormack Lehane grading, attempts of intubation, duration of intubation, success rate of intubation, adjuvant measures needed (stylet, retraction of mouth) for intubation were noted. Results: Patients having predictors of difficult intubation had significant risk of unsuccessful intubation with midline approach (p=0.01 for MPG III/IV, p=0.04 for TMD

Comparison of glottic view and ease of orotracheal intubation with Macintosh and McCoy laryngoscopes in anaesthetised adult patients

Background and aims: This study is aimed at comparing glottic view and ease of intubation with Macintosh and McCoyTM laryngoscopes in adult patients. Methods: One hundred forty consenting patients undergoing elective surgery requiring orotracheal intubation were randomly assigned to two groups for assessment of glottic view and ease of intubation. Cormack-Lehane (CL) glottic view, ease of intubation, laryngoscopy time and intubation time were recorded. Results: All recruited patients completed the study, with a single attempt for successful intubation. Demographic profile was comparable between groups. Glottic view represented as CL grade (Macintosh laryngoscope- grade 1 among 100 patients, 2a in 26, 2b in 12 and 3a in 2 patients; McCoyTM laryngoscope- grade 1 in 105, 2a in 20, 2b in 13 and 3a in 2 patients), requirement of additional manoeuvres like optimal external laryngeal manipulation (OELM)/use of lever for best glottic view (OELM in 40 patients, lever in 35 patients), ease of intubation (Macintosh laryngoscope- grade 1 in 49 patients, grade 2 in 21 patients; McCoyTM laryngoscope- grade 1 in 53 patients, grade 2 in 17 patients), mean laryngoscopy time (6.02 ± 1.91 s with Macintosh and 6.65 ± 2.09 s with McCoyTM laryngoscope) and mean intubation time (15.24 ± 3.01 s with Macintosh and 16.09 ± 3.42 s with McCoyTM laryngoscope) were comparable between laryngoscopes. Conclusion: In adult patients with essentially normal airway, Macintosh and McCoyTM laryngoscopes provide similar glottic view and ease at intubation, with comparable time required for laryngoscopy and intubation when performed by an experienced anaesthesiologist.

Stylet angulation for routine endotracheal intubation with McGrath videolaryngoscope.

Background:The McGrath videolaryngoscope (VL) provides excellent laryngoscopic views, but directing an endotracheal tube can be difficult, and thus the routine use of a stylet is recommended. The goal of this study is to determine the appropriate angle (60° vs 90°) of the stylet when using the McGrath VL by comparing the time to intubation (TTI).Methods:One hundred and forty patients aged 19 to 70 years (American Society of Anesthesiologists classification I or II) who required tracheal intubation for elective surgery were randomly allocated to 1 of 2 groups, at the 60° angle (n = 70) or the 90° angle (n = 70). Anesthesia was induced with propofol, fentanyl, and rocuronium. The primary outcome was TTI assessed by a blind observer. Glottic grade, use of optimal external laryngeal manipulation, failed intubation at first attempt, ease of intubation, and severity of oropharyngeal bleeding were also recorded.Results:The mean TTI was significantly shorter in the 60° group than in the 90° group (29.3 ± 6.4 vs 32.5 ± 9.4 s, P = 0.022). The glottic grade and degree of intubation difficulty were not significantly different between the 2 groups.Conclusions:When intubating the patients with the McGrath videolaryngoscope, the 60° angled stylet allowed for faster orotracheal intubation than did the 90° angled stylet.

McGrath Video Laryngoscopy Facilitates Routine Nasotracheal Intubation in Patients Undergoing Oral and Maxillofacial Surgery: A Comparison With Macintosh Laryngoscopy

The McGrath video laryngoscope (VL) offers excellent laryngoscopic views and increases the success rate of orotracheal intubation in patients with normal and difficult airways. The purpose of this randomized controlled trial was to compare the McGrath VL with the Macintosh laryngoscope to investigate the efficacy of the McGrath VL for routine nasotracheal intubation in patients with an expected normal airway. To address the research purpose, the efficacy of the McGrath VL for routine nasotracheal intubation was compared with that of the Macintosh laryngoscope. The predictor variable was the laryngoscopic technique (McGrath VL vs Macintosh laryngoscope). The outcome variables were the time to successful intubation, laryngoscopic views before and after optimal external laryngeal manipulation (OELM), use of Magill forceps, ease of intubation, and severity of oropharyngeal bleeding. Data from 35 patients undergoing oral and maxillofacial surgery were assessed. The time to intubation was 10.5 seconds shorter in the McGrath group than in the Macintosh group (34.4 ± 13.7 vs 44.9 ± 15.6 seconds; P = .004). The incidence of grade 1 glottic view before OELM was higher in the McGrath group than in the Macintosh group (83 vs 57%; P = .019). The frequency of Magill forceps use was lower in the McGrath group than in the Macintosh group (6 vs 34%; P = .003). McGrath VL facilitates routine nasotracheal intubation in expected normal airways by providing a shorter intubation time and better laryngoscopic views compared with the Macintosh laryngoscope.

In Reply

We thank the authors of these letters for their comments that help to clarify the importance of our study to the readers. As regards the letter from Drs. Xue, Cui, and Cherng, we used a 6.5- to 7.5-mm inner diameter endotracheal tube and a laryngoscope with a Macintosh blade, size 3 in all patients in this study. Moreover, all the cases in which intubation was unsuccessful by the novices were successfully intubated by the anesthesiologists with the use of size 3 Macintosh blade. All the patients in this trial were selected by using the stated inclusion criteria, and their characteristics were controlled as shown in table 1 of original article.1 We cannot comment on the effect of Macintosh blade size on the results of this trial, because it was not varied. The stylet bend angles started with 40 to 50 degree and could be changed by the assistants according to the requirement of the operators.The enrollment of the optimal external laryngeal manipulation to improve laryngeal views was required in some cases of both groups. We agree that the placement of the flashlight (Fenixlight Limited, Shenzhen, China) itself may have a positive effect on the exposure of the glottis compared the patient without any external laryngeal manipulation in direct laryngoscopy group.As regards the letter from Dr. Cherng, we agree as noted above that placement of the flashlight and any pressure applied could have altered or improved exposure of the glottis.

Improvement in Cormack and Lehane grading with laparoscopic assistance during tracheal intubation

Background:To use laparoscope as an easily available and easy to use alternative option to videolaryngoscope.Aims:The aim of the study was to assess the improvement in the glottic view using a conventional direct laryngoscope (DL) assisted by a laparoscope with its endovision system along with the time taken for tracheal intubation.Settings and Design:A prospective, double blind, randomized, controlled study was conducted in a tertiary care centre.Methods:Sixty patients with American Society of Anesthesiologists (ASA) physical status I and II requiring general anaesthesia and tracheal intubation for elective surgery were included in the study. The patients were anaesthetized, paralysed, DL was performed and Cormack and Lehane grade (C and L) noted, followed by the introduction of the laparoscope alongside the flange of the Macintosh laryngoscope and a further C and L grading done as seen on monitor. Demographic data, ASA physical status, airway assessment, mouth opening, modified Mallampatti class, jaw protrusion, thyromental and sternomental distances, optimal external laryngeal manipulation, time taken for intubation, pulse oximetry, blood on; tracheal tube, lip, dentition or mucosal trauma, sore throat, hoarseness of voice, excessive secretions and regurgitation were recorded.Statistical Analysis:Statistical analysis was done using statistics package for social sciences software (17.0 version). A P-value less than 0.05 was considered statistically significant.Results:Eighty-three percent of the patients showed improvement in glottic view after laparoscopic assistance. Eighty-one and 85% of the patients with C and L grade II and III respectively on DL had an improved glottic view with this technique. The mean time to intubate was 37 seconds.Conclusions:Laparoscopic assistance provided a better glottic view than DL in most patients (83%). It has a potential advantage over standard DL in difficult intubation.

Optimal external laryngeal manipulation versus McCoy blade in active position in patients with poor view of glottis on direct laryngoscopy

Successful endotracheal intubation requires a clear view of glottis. Optimal external laryngeal manipulation may improve the view of glottis on direct laryngoscopy with Macintosh blade, but it requires another trained hand. Alternatively, McCoy laryngoscope with elevated tip may be useful. This study has been designed to compare the two techniques in patients with poor view of glottis. Two hundred patients with ‘Grade 2 or more’ view of glottis on direct laryngoscopy with Macintosh blade are included in the study. Optimal external laryngeal manipulation was applied, followed by laryngoscopy with McCoy blade in activated position; and the view was noted in both situations. The two interventions were compared using Chi-square test. The overall changes, in the views, were analyzed with Wilcoxon signed rank test. Both the techniques improved the view of glottis significantly (P<0.05). Optimal external laryngeal manipulation was significantly better than McCoy laryngoscope in active position, especially in patients with Grade 3 or 4 baseline view, poor oropharyngeal class, decreased head extension and decreased submandibular space (odds ratio = 2.36, 3.17, 3.22 and 26.48 respectively). To conclude, optimal external laryngeal manipulation is a better technique than McCoy laryngoscope in patients with poor view of glottis on direct laryngoscopy with Macintosh blade.

Left-molar approach for direct laryngoscopy: is it easy?

For direct laryngoscopy, we compared midline and left-molar approaches with respect to ease of intubation, using a Macintosh blade. We investigated the relationship between failure of the left-molar approach and preoperative risk factors for difficult intubation. With local ethics committee approval, 200 consecutive adult, nonpregnant patients were included in the study. The demographic data, body mass index, Mallampati modified score, interincisor gap, and mentohyoid and thyromental distances were measured preoperatively. First, the Macintosh blade was inserted using the midline approach, and then optimal external laryngeal manipulation (OELM) was applied. Second, the blade was inserted using the left-molar approach. The glottic views were assessed according to the Cormack-Lehane classification before and after OELM in both approaches. In cases where tracheal intubation failed with the left-molar approach, the midline approach was applied again and endotracheal intubation took place. The grade I glottic view obtained using the midline approach without OELM did not change in 94.3% of the patients with the left-molar approach without OELM; in addition, the grade II glottic view improved to grade I in 52.8% of the patients with the same technique (P < 0.001). Although the number of patients with a grade I or II glottic view in the left-molar approach was 197, only 37 patients could be intubated using the left-molar approach. In addition, 59.5% of them were intubated at the second attempt with the left-molar approach, while the incidence of a second attempt was 1.2% with the midline approach (P < 0.001). There was no correlation between the preoperative risk factors for difficult intubation and failure of the left-molar approach. Difficulty in the insertion of the endotracheal tube limits the efficacy of the left-molar approach. It is not possible to predict the failure of intubation with the left-molar approach by considering the preoperative risk factors.

A left paraglossal approach for oral intubation in children scheduled for bilateral orofacial cleft reconstruction surgery – a prospective observational study

Children with orofacial cleft defects are expected to have difficult airways. Conventional midline laryngoscopic approach of oral intubation can lead to iatrogenic tissue trauma. In this study, we evaluated the feasibility of left paraglossal laryngoscopy as a primary technique for airway management in these children. After institutional ethical committee approval and informed consent, we enrolled 21 children with uncorrected bilateral lip and palate deformities (BL CL/P). Anesthesia was induced with halothane (0.5-4%) in 100% oxygen. After obtaining intravenous access, fentanyl 1.5 microg x kg(-1) and atracurium 0.5 mg x kg(-1) were administered. Endotracheal intubation was performed with Miller's straight blade laryngoscope, introduced using left paraglossal approach. Difficulty of intubation was scored according to modified Intubation Difficulty Scale. Data consists of 21 children (15 males and six females), mean age 1.31 +/- 1.18 years and weight 9.27 +/- 2.57 kg. Laryngoscopic view obtained was CL II (7[33.3%]) and CL I (14[66.6%]) respectively (Figure 1). All the children could be easily intubated using left paraglossal approach, only 2/3 of them needed optimal external laryngeal manipulation to help achieving it. Though intubation could be done in the first attempt in 19 children, two infants (9 1/2 and 11 months) required one size smaller endotracheal tube and were intubated in the second attempt using left paraglossal approach. Perioperative course was uneventful in all the children. Keeping in mind midline tissue support loss in cleft deformities, we propose routine use of left paraglossal laryngoscopic approach for intubating children with uncorrected BL CL/P anomalies.

Left molar approach improves laryngeal view in patients with simulated limitation of cervical movements

Immobilized cervical spine, because of either diseases or stabilizing devices, poses considerable difficulties with endotracheal intubation due to poor laryngoscopic view. The left molar (LM) approach has been shown to be useful in difficult sporadic intubation cases. We evaluated efficacy of this approach of laryngoscopy to improve laryngeal view in patients with simulated limitation of cervical movements. Thirty patients of American Society of Anesthesiologists grade I/II, who were scheduled to undergo routine surgical procedures under general anaesthesia and endotracheal intubation, were studied. A two-piece semi-rigid cervical collar was used to immobilize the cervical spine. Under standardized anaesthesia and neuromuscular blocking agent, conventional laryngoscopy using a curved Macintosh blade was performed and glottic view was recorded with and without optimal external laryngeal manipulation (OELM). Subsequently, in the same subjects the laryngoscope blade was withdrawn and re-inserted through the LM approach and glottic view was recorded with and without OELM followed by tracheal intubation. With the conventional approach, laryngeal view was recorded as grade II in five patients, grade III in 24 patients, and grade IV in one patient. However, with the LM approach, laryngeal view was grade I in 25 patients, grade II in five patients, and grade III or IV in none (P<0.001). Tracheal intubation with the LM approach required the use of a flexible stylet to guide the tube tip into the larynx. The laryngeal view is improved by the LM approach in patients with simulated limited cervical movements with a high success rate of tracheal intubation, but requires orientation for negotiation of the tube through the narrow oropharyngeal space available.

Comparative Study Of Molar Approaches Of Laryngoscopy Using Macintosh Versus Flexitip Blade

The molar approach of laryngoscopy with the Macintosh blade, compared to the Flexitip blade, was reported to improve glottic view. The authors studied the right molar, midline and left molar approach. They compared the Macintosh blade with optimal external laryngeal manipulation (OELM)5 versus the Flexitip blade with lever activation and also pressure responses and complications in various approaches and blades were studied. Method:A series of 180 adult patients who underwent general anaesthesia and tracheal intubation was studied. Laryngoscopy was carried out using a Macintosh no.3 (45 patients) or 4 (45 patients) or Flexitip no. 3 (45 patients) or No.¬ 4 (45 patients). Three consecutive trials of direct laryngoscopy using the middle, left molar and right molar approach were carried out under full muscle relaxation. The best glottic view was recorded for each approach with and without OELM in case of Macintosh or with and without lever activation in case of the Flexitip blade.

Comparison of Cormack Lehane grade, Head extension angle, Laryngoscope Blade Levering Motion angle and pressor response with Macintosh, McCoy and Balloon Laryngoscopy

Balloon laryngoscopy was reported to improve glottic view. The authors studied Macintosh, McCoy's3 and Balloon laryngoscopy 7,8. They compared the Macintosh blade with optimal external laryngeal manipulation (OELM) 2 versus the McCoy's blade with lever activation and Balloon laryngoscope with Balloon inflation with 3 cc of air. Method: A series of 120 adult patients who underwent general anaesthesia and tracheal intubation in neutral position with Rigid Cervical neck collar was studied. Laryngoscopy was carried out using a Macintosh no.3 (15 patients) or 4 (15 patients) or McCoy's no. 3 (15 patients) or No. 4 (15 patients) or Balloon laryngoscope (R1L2) no. 3 (15 patients) or 4 (15 patients) or Balloon laryngoscope (L1R2) no. 3 (15 patients) or 4 (15 patients). The best glottic view was recorded for each approach with and without OELM in case of Macintosh or with and without lever activation in case of the McCoy's blade or with and without inflation of balloon in Balloon laryngoscopy. Head extension Angle and Laryngoscope Blade Levering Motion Angle were also measured with the help of Goniometer. Results: The McCoy's blade gives better glottic visualization on laryngoscopy than other laryngoscopes. The balloon laryngoscope blade proved better than the Macintosh laryngoscope blade in glottic visualization. In balloon laryngoscopy, L1R2 group performed slightly better than R1L2 in glottic visualization. Head extension angle and laryngoscopy blade levering motion angle were almost same in all types of laryngoscopy Conclusion: McCoy's blade was superior for glottic visualization followed by balloon laryngoscope blade pressure response was significant in all approaches of laryngoscopy. There was significant change in pulse rate, and systolic blood pressure in McCoy's laryngoscopy group as compared to other groups.

Takotsubo Cardiomyopathy after General Anesthesia for Eye Surgery

Takotsubo Cardiomyopathy after General Anesthesia for Eye Surgery

Successful Intubation of a Double-Lumen Endobronchial Tube Using the Modified Seldinger Technique Following Intubation of a Single-Lumen Endotracheal Tube in a Case of Difficult DLT Intubation -A case report-

Intubation of an double-lumen endotracheal tube (DLT) in either a normal or a difficult airway may be more difficult than the intubation of a single-lumen endotracheal tube (ETT). A 72-year-old man undergoing right upper lobectomy could not be intubated with either a 37 Fr or a 35 Fr DLT after induction of anesthesia due to an inability to visualize the glottis. Difficult intubation had not been foreseen, but inspection through the laryngoscope revealed a Cormack grade III condition. Following two attempts to place the DLT, fibroptic bronchoscopy also proved unsuccessful. We intubated a 8.0 mm ETT with OELM (optimal external laryngeal manipulation) and followed this by inserting an infusion set catheter into the ETT as a guiding stylet. The ETT was then withdrawn with the catheter in situ in the trachea, and a 35 Fr DLT successfully introduced. After removing the catheter, the position of the DLT was corrected by fibroptic bronchoscopy. No further complication occurred and surgery was finished satisfactory. We achieved successful DLT intubation using the modified Seldinger technique with an infusion set catheter through an intubated ETT in a patient with an unanticipated difficult airway.

Management of unanticipated difficult intubation: a survey of current practice in the Oxford region.

Unanticipated difficulty in tracheal intubation in an anaesthetized patient has always been a cause of concern to anaesthesiologists. This difficulty may lead to morbidity and mortality. This survey was carried out to determine the technique commonly favoured in centres in the Oxford region in the UK for the management of unanticipated difficult intubation. We conducted a clinical scenario-based questionnaire survey of 181 anaesthesiologists in the Oxford region. In this scenario, difficulty in endotracheal intubation is recognized only after induction of anaesthesia. A number of options were available to deal with this situation. We used this scenario as a tool to gain insight into the training and the training needs of anaesthesiologists at various levels of training. Of the 181 questionnaires sent, we received 143 (79%) completed replies. The vast majority (141/143 (99%)) of anaesthesiologists would use a gum-elastic bougie together with head and neck positioning and optimal external laryngeal manipulation to gain the best attempt at intubation. If intubation still failed, overall 129/143 (90%) had a back-up plan, while 14/143 (10%) had no plan. Flexible fibreoptic techniques were more commonly planned by 92/143 (64%) anaesthesiologists compared to blind techniques which were less commonly planned by 37/143 (26%) anaesthesiologists. Differences in choice of technique among anaesthesiologists in teaching and district general hospitals were not significant (P = 0.87). Overall, trainees were less likely to choose fibreoptic techniques compared to consultants (P = 0.0009) and would use blind techniques or ask a more experienced colleague to take over. The main reason for the choice was previous experience with the technique. Although fibreopric techniques were most commonly planned, these were less often chosen by trainees than consultants due to lack of experience/training, while unavailability of intubating laryngeal mask airway (Intavent) was an additional issue precluding its use as an adjunct to intubation.