Rate Of Difficult Intubation Research Articles

Rate of difficult intubation during caesarean delivery: A single centre before/after standardised airway management implementation study

BackgroundThe use of general anaesthesia (GA) for caesarean delivery (CD) introduces the risk of both difficult and failed intubation. Various strategies may be utilised to reduce this risk; however, not all are supported by evidence. We analysed the rate of difficult intubation following implementation of three recommendations specific to airway management in CD. MethodsThis was a retrospective single-center study of CD cases performed under GA at a tertiary care center between January 2013 and December 2022. Cases with GA induced after delivery or with incomplete airway management records were not included in the analysis. We compared outcomes for cases before (2013–2018) versus after (2019–2022) implementation of three specific recommendations: (1) video laryngoscopy (VL) for the first intubation attempt; (2) the presence of a second anesthetist; (3) use of endotracheal tube size 6.5 mm. The primary outcome was difficult intubation, defined as a composite variable (> 1 intubation attempt, use of a rescue device, SpO2 < 90%). We conducted univariable and adjusted analyses of plausible variables associated with difficult intubation, including age, body mass index, predicted difficult airway, and each of three recommendations. ResultsWe identified 1462 cases, 922 before and 540 after implementation. The frequency of difficult intubation was similar with 239 (25.9%) before versus 135 (25.0%) after implementation (p = 0.71; 95% CI −0.03 to 0.05). The recommendations were not associated with a decreased likelihood of difficult intubation in the univariable and adjusted models. Adoption of all three recommendations was significantly more frequent in the post-implementation period. ConclusionImplementation of standardised airway management recommendations had no significant impact on difficult intubation rate, though adoption of all three recommendations was not universal.

Evaluation of upper airway ultrasonographic measurements in predicting difficult intubation: A cross-section of the Turkish population.

Studies have shown that there are differences in clinical evaluation parameters and difficult intubation rates among different ethnic populations. In our study, we aimed to evaluate the efficacy of upper airway clinical and ultrasonographic measurement methods in Turkish population. Our study is a single-center, prospective, observational study conducted with 402 patients. All patients underwent clinical airway measurements which are routinely used in pre-anesthetic evaluation. In addition, ultrasonographic anterior neck soft tissue thickness measurements of each patient were made and recorded. Among the clinical measurements, we found the neck circumference/thyromental distance (TMD) ratio to be significant with a cut-off value of 5.5 and a sensitivity of 92.9% and a specificity of 88.3%, while among the ultrasonographic anterior neck measurements, we found the skin-epiglottic distance to be the most sensitive measurement. We found that there was a positive relationship between the neck circumference/TMD ratio and skin-epiglottis. In our study, we found that routine measurement methods used in airway examination alone are not sufficient, and measurements that take into account the body proportions of the patients, such as the neck circumference/TMD ratio and the ultrasonographic evaluations are more useful in predicting difficult intubation.

The Effects of Thyroid Gland Volume and Weight on Surgical Approach Selection and Anesthesia Management in Retrosternal Goiter

Background: Retrosternal goiter surgery is a technically challenging procedure. Selecting the appropriate surgical approach is critical in preventing surgical and anesthesia complications. Objectives: This retrospective clinical study aimed to investigate the role of thyroid volume and weight in the development of retrosternal goiter and the importance of special anesthesia management in patients with retrosternal goiter, which is a potentially difficult airway candidate. Methods: Retrosternal goiter was detected in 125 patients through ultrasonography. Patients were divided into cervical surgery (CA) and sternotomy (ECA) groups. Volumetric measurements were performed ultrasonographically. Patients' demographics, preoperative thyroid ultrasonography features, American Society of Anesthesiologists (ASA) classifications, Mallampati classifications, intubation characteristics, perioperative and postoperative patient data, and postoperative thyroid specimen weights were recorded. Results: A total of 106 patients (32 male and 74 female) were operated on for bilateral total thyroidectomy. Total thyroidectomy was performed with CA in 98 (92.5%) patients and with ECA in 8 (7.5%) patients. Malignancy was detected in 4 (3%) of 106 operated cases. All of the malignant cases were seen in patients with a cervical approach. When the volumetric measurements of both groups were compared, the volume values were significantly higher in the ECA group (P=0.032). 67 patients were ASA I and 39 patients were ASA II. 64 patients were defined as Mallampati Class I, 36 patients as Mallampati Class II, and 6 patients as Mallampati Class III. Intubation was performed on the third attempt for 5 patients and 8 patients with Mallampati I and Mallampati II, respectively. The rate of difficult intubation was statistically significant in the ECA group (P=0.019). Conclusion: Predicting ECA requirement in the preoperative period is closely related to the preoperative volumetric analysis of the thyroid gland with three-dimensional ultrasonography. In addition, since anesthesia management is difficult in patients who need ECA, volumetric analysis has become even more critical.

Evaluation of anthropometric measurements and clinical tests in the diagnosis of difficult airway in patients undergoing head and neck surgery.

The aim of this study is to research the incidence of difficult airways and the effectiveness of anthropometric measurements and clinical tests used to predict difficult airways in patients undergoing head and neck surgery. This study was performed on a total of 200 patients over the age of 18 who underwent head and neck surgery between December 2019 and March 2020. The demographic data of the patients in the preoperative period, previous operations/ radiotherapy history applied to the head and neck region, and obstructive sleep apnea syndrome symptoms were recorded. In the physical examination, the jaw structure, mouth opening, jaw movement, and tooth structure of the patients, modified Mallampati classification, head and neck movements, neck circumference, thyromental and sternomental distance, atlantooccipital joint mobility, upper lip bite test, Wilson risk scoring, and Cormack-Lehane classification were evaluated. The difficult laryngoscopy rate was identified as 19%, and the difficult intubation rate as 8%. Operation history related to head and neck (p = 0.002), presence of at least two of the obstructive sleep apnea syndrome symptoms (p = 0.008), Modified Mallampati score (p = 0.009), Wilson risk score (p = 0.004), upper lip bite test (p < 0.0001) and mouth opening (p = 0.001) were found to be associated with difficult laryngoscopy. Modified Mallampati score (p = 0.002), Wilson risk score (p < 0.0001), upper lip bite test (p < 0.0001), mouth opening (p < 0.0001), sternomental distance (p = 0.003), Atlantooccipital joint mobility (p = 0.001), and Cormack-Lehane classification (p < 0.0001) were found to be associated with difficult intubation. According to multiple logistic regression analysis, the results obtained for sternomental distance and mouth opening were OR 0.8, 95% CI 0.6-1.1 and OR 0.2, 95% CI 0.1-0.4, respectively. In patients who underwent head and neck surgery, it was observed that the frequency of difficult airway was higher, and particularly the Modified Mallampati score, Wilson risk score, upper lip bite test, and mouth opening were associated with both difficult laryngoscopy and difficult intubation.

An assessment of perioperative respiratory adverse events and difficult intubation in pediatric patients with Trisomy 21.

Several prior studies have demonstrated an association between trisomy 21 and airway-related anesthetic complications. However, there is a paucity of large clinical studies characterizing the airway challenges associated with trisomy 21. In this analysis, we examine anesthetic-related airway complications in children with trisomy 21 and compare our findings to well-matched controls. A chart review of all general anesthetics occurring between 2011 and 2017 at a single pediatric hospital was performed. Children with trisomy 21 were identified. Matched controls were created using a 1:1 propensity score and controlling for patient sex, patient age, surgical specialty, airway management, and anesthetic induction technique. The primary outcomes were the numbers of difficult intubations and perioperative respiratory adverse events. Secondary outcomes included the number of intubation attempts and the Cormack-Lehane grade in each cohort. A total of 2702 anesthetic records were reviewed. Propensity score matching resulted in adequately matched control groups as indicated by a standard mean difference below 0.2 in each case. Logistic regression analysis between trisomy 21 patients and matched controls demonstrated that the trisomy 21 cohort had a higher incidence of perioperative respiratory adverse events (OR 2.04, 95% CI 1.34-3.09, p=.0008) due largely to a higher incidence of airway obstruction (1.7% vs. 0.2%, p=.0005). The trisomy 21 group had a lower rate of difficult intubation (OR 0.26, 95% CI 0.07-0.91, p=.034). There was no association between trisomy 21 and the number of intubation attempts (RR 0.99, 95% CI 0.88-1.13, p=.92) or Cormack-Lehane grade (RR 0.95, 95% CI 0.87-1.05, p=.35). The trisomy 21 cohort had an increased incidence of perioperative respiratory adverse events compared to matched controls, largely secondary to a higher rate of obstructed ventilation, but without statistically different rates of laryngospasm, bronchospasm, postextubation stridor, or other desaturation events. Our trisomy 21 cohort had a decreased incidence of difficult intubation. There was no association between trisomy 21 and number of attempts required to successfully place an endotracheal tube or a less favorable CL grade. Compared to matched controls, children with trisomy 21 have a lower incidence of difficult intubation and a higher incidence of perioperative respiratory adverse events, largely due to increased rate of airway obstruction.

CLINICAL AND EPIDEMIOLOGICAL PROFILE OF PATIENTS WITH DIFFICULT INTUBATION IN MAXILLOFACIAL SURGERY AND STOMATOLOGY.

Aim of the work: To describe clinical and epidemiological profile of patients with difficult intubation in maxillofacial surgery and stomatology. &#x0D; Methods: This is a descriptive retrospective study over a period of two years (April 2017 to May 2019) at the University Hospital Joseph Dieudonné Rakotovao (CHU - JDR) &#x0D; Antananarivo. This includes all patients whose intubation lasted more than 10 minutes and / or more than three attempts, or could not be performed. &#x0D; Results: Twenty-eight (28) patients were collected with difficult intubation rate of 8%. A male predominance was found (sex ratio = 2.25) and the lesions are mainly of tumoral origin (54%), sitting at the level of the mandible (43%) and locating on the right side (54%). The classification of Mallampati and measurement of mouth opening could not be evaluated in 39% and 18% of cases respectively. For the classic criteria that were able to evaluate: the classification of mallampati III and IV = 59%, the mouth opening less than 3.5 cm = 26% and the mento - thyroid distance less than 6cm = 4%. &#x0D; Conclusion: Although the classical predictive criteria for difficult intubation are reliable, they cannot always be correctly assessed in maxillofacial surgery. And particular features of the lesion have been found in patients who presented with difficult intubation. Hence the interest of carrying out an analytical study in order to elaborate a predictive score based on the classic criteria and the characteristics of the lesion.

Pretreatment with somatostatin analogs does not affect the anesthesiologic management of patients with acromegaly.

Acromegaly may be associated with an increased risk of complex intraoperative management and anesthetic complications. No study addressed whether pretreatment with somatostatin receptor ligands (SRLs) affects anesthesiologic management. We studied 211 consecutive acromegalic patients who had a recorded intraoperative computerized anesthetic record (ICAR) available for analysis. Ninety-six (45.5%) patients were SRL-pretreated while 115 patients were treatment naïve. Treatment with SRLs reduced mean basal growth hormone level from 23.8 ± 4.2 to 5.9 ± 1.3µg/L. Normalization of insulin-like growth factor-1 was achieved in 26 patients (27.1%). The frequency of comorbidities at surgery was similar in the two groups. Five patients with difficult intubation were naïve (4.3%) as compared with 5 SRL-pretreated patients (5.2%; P = 1.0). ICAR registration did not show any significant change of intraoperative vital parameters in the two groups of patients as well as in the intraoperative utilization of drugs. Total duration of anesthesia and surgery were similar in the two groups. Four patients with an intraoperative adverse event were naïve (3.5%) as compared with 4 SRL-pretreated patients (4.2%; P = 1.00). Remission of disease occurred in 83 of 114 naïve patients (72.8%) and in 57 of 93 SRL-pretreated patients (61.3%; P = 0.11). SRL-pretreatment of patients with acromegaly had no significant impact on intraoperative anesthesiologic management. Despite a better Cormack-Lehane score in SRL-pretreated than in naïve patients, the rate of difficult intubation was similar in both groups. SRL-pretreatment did not affect the rate of surgical remission or complications as well.

Difficult Intubation in Patients with Carcinoma of the Larynx and Hypopharynx

Introduction: ASA defines difficult intubation as tracheal intubation which requires more than three attempts with direct laryngoscopy. In a major study including 3325 patients, three or more attempts for direct laryngoscopy were needed in 1,9%, and intubation failure was observed in 0,1%. The Aim of the study is to determine difficult intubation rates in patients with laryngeal and hypopharyngeal carcinoma. Materials and Methods: A prospective cohort study including 100 patients undergoing microlaryngeal surgery in the Department of Otorhinolaryngology at the University Hospital „Queen Giovanna“ – ISUL, Sofia, in the period 2014-2017. Results and discussion: Difficult intubation is observed in 8 patients (8%). Impossible intubation is observed in 12 patients (12%). The study showed that the major factor leading to difficult endotracheal intubation in patients with carcinoma of the larynx and hypopharynx is the laryngeal obstruction caused by the malignant process. Conclusion: difficult and impossible intubation rates in patients undergoing laryngectomies are higher than in the common population due to the obstruction caused by the carcinoma.

Retrospective Evaluation of Patients who Underwent Laparoscopic Bariatric Surgery.

In the present study, we aimed to retrospectively evaluate the preoperative characteristics, intraoperative and postoperative results of patients who underwent laparoscopic obesity surgeries. After obtaining the approval of the Ethics Committee, records of patients who underwent laparoscopic obesity surgery from January 2013 to December 2016 were reviewed. Demographic characteristics, medications used in anaesthesia and analgesia, the duration of recovery unit/hospital stay, intensive care unit/mechanical ventilation requirements and complications were recorded. A total of 329 ASA II-III patients over a 3-year period were operated. Thiopental and propofol were administered at induction, sevoflurane, isoflurane and desflurane were administered for the maintenance, and vecuronium and rocuronium were administered to aid in neuromuscular blockage. The mean durations of recovery unit and hospital stays were 30.80±6.01 minutes and 4.27±1.68 days, respectively. The hypnotic agent, muscle relaxant or inhalation anaesthetics used did not have a significant effect on the duration of recovery unit and hospital stay. Mask ventilation and intubation were noted to be difficult in 5.5% and 8.5% of the cases, respectively. The presence of obstructive sleep apnoea syndrome and high body mass index and Mallampati scores significantly increased difficult mask ventilation and difficult intubation rates. Four patients were transferred to intensive care unit for close monitoring. Two patients were re-operated on, two patients had rhabdomyolysis, one patient had Wernicke's encephalopathy and two patients had peripheral neuropathy. Perioperative mortality did not occur in any patient. We believe that appropriate patient selection, the use of well-designed anaesthesia and surgical protocols play important roles in increasing the success rate of patient outcomes and early and late complications in laparoscopic obesity surgery.

The association of body mass index with difficult tracheal intubation management by direct laryngoscopy: a meta-analysis

BackgroundObesity is a serious disorder and may bring about many difficulties of perioperative management. A systematic review was conducted to assess the association between obesity and difficult intubation.MethodsWe searched electronic databases for related reviews and references of meta-analyses on August 14, 2017. The databases of PubMed, Embase, and the Cochrane controlled trials register were searched compared obese with non-obese patients in which difficult intubation rate of the adult population were retrieved. Patients with a BMI ≥ 30 kg·m− 2 were considered obese. The primary outcome was difficult tracheal intubation; secondary outcomes were the rates of difficult laryngoscopy and Mallampati score ≥ 3. This review included papers published from 1998 to 2015.ResultsThis review included 204,303 participants in 16 studies. There was a statistically significant association between obesity and risk of difficult tracheal intubation (pooled RR = 2.04, 95% CI: 1.16–3.59, p = 0.01; I2 = 71%, p = 0.008, Power = 1.0). It also showed significantly association between obesity and risk of difficult laryngoscopy (pooled RR = 1.54, 95% CI: 1.25–1.89, p < 0.0001; I2 = 45%, p = 0.07, Power = 1.0), obesity and risk of Mallampati score ≥ 3 (pooled RR = 1.83, 95% CI: 1.24–2.69, p = 0.002; I2 = 81%, p < 0.00001, Power = 0.93). However, there were no association of obesity and risks of difficult intubation compared with non-obesity in the cohort studies (pooled RR = 3.41, 95% CI: 0.88–13.23, p = 0.08; I2 = 50%, p = 0.14) and the elective tracheal intubation (pooled RR = 2.31, 95% CI: 0.76–6.99, p = 0.14; I2 = 73%, p = 0.01), no associated with an increased risk of difficult laryngoscopy in the sniffing position (pooled RR = 2.00, 95% CI: 0.97–4.15, p = 0.06; I2 = 67%, p = 0.03).ConclusionObesity was associated with an increased risk of difficult intubation, difficult laryngoscopy and Mallampati score ≥ 3 in adults patients undergoing general surgical procedures. However, there were no association of obesity and risks of difficult intubation compared with non-obesity in the cohort studies and the elective tracheal intubation, no associated with an increased risk of difficult laryngoscopy in the sniffing position. Future analyses should explore the association of BMI and difficult airway.

Successful airway management with combined use of McGrath® MAC video laryngoscope and fiberoptic bronchoscope in a severe obese patient with huge goiter -a case report.

Huge goitor can lead to tracheal compression and hence difficulty in intubation. This is compounded by severe obesity. Failed tracheal intubation in difficult intubation is a serious event that may lead to increased patient morbidity and mortality. Current intubation rescue techniques and combination of different rescue techniques may increase the success rate of difficult intubation. In a 47-year-old female patient, with severe obesity and a huge goiter, our attempts at intubation using direct laryngoscope, video laryngoscope, and awake fiberoptic bronchoscope had failed. We succeeded by applying video laryngoscope to improve visualization of the airway and fiberoptic bronchoscope as a stylet for endotracheal tube.

Difficult laryngoscopy and tracheal intubation: observational study

Since anesthesia complications associated with unexpected difficult airway are potentially catastrophic, they should be avoided. The modified Mallampati test and jaw-thrust maneuver enable the identification of difficult airway. The aim of this study was to associate the modified Mallampati test and the jaw-thrust maneuver with laryngoscopy (Cormack-Lehane) in an attempt to identify a better predictor of difficult airway in an adult population undergoing elective surgery. A cross-sectional study in which 133 adult patients undergoing elective surgery requiring tracheal intubation were analyzed. The accuracy and specificity of the modified Mallampati test and jaw-thrust maneuver were assessed by correlating them with difficult laryngoscopy (Cormack-Lehane Degrees 3 and 4). In the 133 patients evaluated the difficult intubation rate found was 0.8%; there was association between the two predictive tests proposed (p=0.012). The values of 94.5% for specificity and 95.4% for accuracy were found for the jaw-thrust maneuver and for the modified Mallampati test, the values found were 81.1% and 81.2%, respectively. Kappa agreement identified a result of 0.240 between jaw-thrust maneuver and Cormarck-Lehane, which was considered reasonable. On the other hand, a poor agreement (κ=0.06) was seen between modified Mallampati test and Cormarck-Lehane test. The jaw-thrust maneuver presented superior accuracy and agreement than the modified Mallampati test, showing the ability to identify a difficult airway. It is necessary to emphasize the association of tests in the evaluation of patients, emphasizing their complementarity to minimize the negative consequences of repeated laryngoscopies.

Difficult laryngoscopy and tracheal intubation: observational study

IntroductionSince anesthesia complications associated with unexpected difficult airway are potentially catastrophic, they should be avoided. The modified Mallampati test and jaw-thrust maneuver enable the identification of difficult airway. The aim of this study was to associate the modified Mallampati test and the jaw-thrust maneuver with laryngoscopy (Cormack–Lehane) in an attempt to identify a better predictor of difficult airway in an adult population undergoing elective surgery. MethodA cross-sectional study in which 133 adult patients undergoing elective surgery requiring tracheal intubation were analyzed. The accuracy and specificity of the modified Mallampati test and jaw-thrust maneuver were assessed by correlating them with difficult laryngoscopy (Cormack–Lehane Degrees 3 and 4). ResultsIn the 133 patients evaluated the difficult intubation rate found was 0.8%; there was association between the two predictive tests proposed (p=0.012). The values of 94.5% for specificity and 95.4% for accuracy were found for the jaw-thrust maneuver and for the modified Mallampati test, the values found were 81.1% and 81.2%, respectively. Kappa agreement identified a result of 0.240 between jaw-thrust maneuver and Cormack–Lehane, which was considered reasonable. On the other hand, a poor agreement (κ=0.06) was seen between modified Mallampati test and Cormack–Lehane test. ConclusionThe jaw-thrust maneuver presented superior accuracy and agreement than the modified Mallampati test, showing the ability to identify a difficult airway. It is necessary to emphasize the association of tests in the evaluation of patients, emphasizing their complementarity to minimize the negative consequences of repeated laryngoscopies.

Predicting Difficult Intubation in Emergency Department by Intubation Assessment Score.

BackgroundThe difficult intubation is associated with failure of emergency tracheal intubation. This study aimed to develop and validate a model for predicting difficult intubation in emergency department (ED).MethodsA cross-sectional study was conducted in the ED. We collected data from all consecutive adult patients who underwent emergency tracheal intubation. Patients were excluded if they were intubated by low experience intubator. The difficult intubation was defined by grade III or IV of Cormack and Lehane classification. We used multivariable regression model to identify significant predictors of difficult intubation and weighted points proportional to the beta coefficient values. The ability to discriminate was quantified by using the area under receiver operating characteristics curve (AuROC). The bootstrapping method was used to validate the performance.ResultsA total of 1,212 intubations were analyzed. One hundred and fifty-seven intubations were enrolled in difficult intubation group. Five independence predictors were identified, and each was assigned a number of points proportional to its beta coefficient: male gender (one), large tongue (two), limit mouth opening (two), poor neck mobility (two), and presence of obstructed airway (three). Intubation assessment score model was created and applied to all subjects. The AuROC was 0.81 (95% confidence interval (CI): 0.77 - 0.85) for the development dataset, and 0.80 (95% CI: 0.76 - 0.85) for the validation dataset. We defined three risk groups: low risk (zero to one points), intermediate risk (two to three points), and high risk (above three points), and the difficult intubation rate was 4.7%, 22.5%, and 53.6%, respectively.ConclusionsIntubation assessment score model was constructed from patients’ simple characteristics and performed well in predicting difficult intubation and can discriminate between with and without difficult intubation.

Evaluation of emergency pediatric tracheal intubation by pediatric anesthesiologists on inpatient units and the emergency department.

There are limited data on pediatric emergency tracheal intubation on inpatient units and in the emergency department by anesthesiologists. This retrospective cohort study was designed to describe the frequency of difficult intubation and adverse events associated with emergency tracheal intubation performed by pediatric anesthesiologists in a large children's hospital. All emergency tracheal intubation on inpatient units and the emergency department performed by pediatric anesthesiologists over a 7-year period in children <18 years were identified by querying our perioperative clinical information system. Medical records were comprehensively reviewed to describe the emergency intubation process and outcomes. One hundred and thirty-two intubations from 120 children (median age 3.3 years) were eligible. The majority of emergency tracheal intubations were successful with 1-2 laryngoscopy attempts, while 14 (10.6%) were difficult. Despite grade 3 view in 3/14 cases, the airway was secured after multiple direct laryngoscopy attempts. Eleven required use of an alternative airway device to secure the airway. A preexisting airway abnormality or craniofacial abnormality was present in 57% of cases with difficult intubation including half with micrognathia or retrognathia. Major intubation-related adverse events such as aspiration, occurred in 5 (3.8%) emergency tracheal intubations. Mild-to-moderate intubation-related adverse events occurred in 23 (17.4%) emergency tracheal intubations including mainstem bronchus intubation (13.6%). A significant rate of difficult intubation and mild-to-moderate intubation-related adverse events were found in emergency tracheal intubations on inpatient units and the emergency department in children performed by a pediatric anesthesiology emergency airway team. Difficult intubation was observed frequently in children with preexisting airway and craniofacial abnormalities and often required the use of an alternative airway device to successfully secure the airway.

Mucopolysaccharidosis: Otolaryngologic findings, obstructive sleep apnea and accumulation of glucosaminoglycans in lymphatic tissue of the upper airway

ObjectiveThe aim of this study is to evaluate otolaryngologic problems (upper airway obstruction, obstructive sleep apnea, restriction of mouth opening, middle ear effusion, hearing and breathing problems) and their treatments on mucopolysaccharidoses (MPS) patients and to investigate accumulation of glucosaminoglycans (GAG) in the upper airway biochemically and pathologically. Methods76 MPS patients were evaluated. Forty-two MPS patients underwent polysomnography (PSG) for obstructive sleep apnea (OSA). Pre- and postoperative PSG results of 18 patients were compared. The success and complications of treatments for OSA in MPS were evaluated. Biochemical and histopathological accumulation of GAG in tonsil and adenoid tissue and middle ear effusion were analyzed and compared with the control group. ResultsForty patients out of 42 tested with PSG had OSA (95%). Adenoid grade, Mallampati grade, restricted mouth opening, rate of difficult intubation were significantly different among MPS subtypes. MPS types III and IV had significantly lower Mallampati scores; type VI had significantly worse mouth opening; and type III had significantly better mouth opening and higher rate of easy intubation when compared to other MPS types. There was no significant difference between MPS subtypes according to tonsil grade, adenoid grade, rate of otitis media with effusion and OSA severity. Statistically significant difference was found between GAG accumulation in adenoid tissue and middle ear effusion of MPS and control group (p<0.05). However, GAG accumulation in tonsil was not significantly different between MPS and control group. There was a statistically significant improvement in postop Apnea–Hypopnea Index (AHI) compared to preop AHI (p<0.05). ConclusionsMost MPS patients have airway obstruction and OSA due to adenotonsillar hypertrophy. Most of these children benefit from adenotonsillectomy, after which OSA significantly improves. They experience high recurrence rate after adenoidectomy; though this is not clinically problematic. They also suffer from conductive hearing loss due to OME, which has to be treated with ventilation tube insertion. However, such operations are usually complicated by difficult endotracheal intubation and restricted mouth opening. Sometimes tracheotomy may be necessary. Tracheotomy is also highly complicated in MPS patients. Significant accumulation of GAG in middle ear fluid and adenoid tissue is present; however, GAG appears not to accumulate in tonsillar tissue.

Implementation of a combo videolaryngoscope for intubation in critically ill patients: a before–after comparative study

Airway management in intensive care unit (ICU) patients is challenging. The main objective of this study was to compare the incidence of difficult laryngoscopy and/or difficult intubation between a combo videolaryngoscope and the standard Macintosh laryngoscope in critically ill patients. In the context of the implementation of a quality-improvement process for airway management, we performed a prospective interventional monocenter before-after study which evaluated a new combo videolaryngoscope. The primary outcome was the incidence of difficult laryngoscopy (defined by Cormack grade 3-4) and/or difficult intubation (more than two attempts). The secondary outcomes were the severe life-threatening complications related to intubation in ICU and the rate of difficult intubation in cases of predicted difficult intubation evaluated by a specific score (MACOCHA score ≥3). Two hundred and ten non-selected consecutive intubation procedures were included, 140 in the standard laryngoscope group and 70 in the combo videolaryngoscope group. The incidence of difficult laryngoscopy and/or difficult intubation was 16 % in the laryngoscope group vs. 4 % in the combo videolaryngoscope group (p = 0.01). The severe life-threatening complications related to intubation did not differ between groups (16 vs. 14 %, p = 0.79). Among the 32 patients with a MACOCHA score ≥3, there were significantly more patients with difficult intubation in the standard laryngoscope group in comparison to the combo videolaryngoscope group [12/23 (57 %) vs. 0/9 (0 %), p < 0.01]. The systematic use of a combo videolaryngoscope in ICU was associated with a decreased incidence of difficult laryngoscopy and/or difficult intubation.

Video Laryngoscopy is Associated With Increased First Pass Success and Decreased Rate of Esophageal Intubations During Urgent Endotracheal Intubation in a Medical Intensive Care Unit When Compared to Direct Laryngoscopy

To compare the complication rates of urgent endotracheal intubation (UEI) performed by pulmonary critical care medicine (PCCM) fellows and attending intensivists using a direct laryngoscope (DL) versus a video laryngoscope (VL) in a medical intensive care unit (MICU). We studied all UEIs performed from November 2008 through July 2012 in an 18-bed MICU in a university-affiliated hospital. All UEIs were performed by 15 PCCM fellows or attending intensivists using only the DL from November 2008 through February 2010 and the VL from March 2010 to July 2012. Throughout the entire study period, the UEI team leader recorded complications of the procedure using a standard data collection form immediately following the completion of the procedure. This permitted a comparison of complication rates between the DL and the VL. A total of 140 UEIs were performed using the DL and 252 using the VL. Using the DL, the esophageal intubation rate was 19% and the difficult intubation rate was 22%; using the VL, the esophageal intubation rate was 0.4% and the difficult intubation rate was 7%. There was no significant difference in the rate of severe hypotension, severe desaturation, aspiration, dental injury, airway injury, or death between the 2 groups. The use of the VL for UEI performed by PCCM fellows is associated with a reduction in the rate of esophageal intubation and difficult endotracheal intubation when compared to the use of the DL.

Evolving role of video laryngoscopy for airway management in the emergency department

Evolving role of video laryngoscopy for airway management in the emergency department

Out-of-Hospital Tracheal Intubation With Single-Use Versus Reusable Metal Laryngoscope Blades: A Multicenter Randomized Controlled Trial

Emergency tracheal intubation is reported to be more difficult with single-use plastic than with reusable metal laryngoscope blades in both inhospital and out-of-hospital settings. Single-use metal blades have been developed but have not been compared with conventional metal blades. This controlled trial compares the efficacy and safety of single-use metal blades with reusable metal blades in out-of-hospital emergency tracheal intubation. This randomized controlled trial was carried out in France with out-of-hospital emergency medical units (Services de Médecine d'Urgence et de Réanimation). This was a multicenter prospective noninferiority randomized controlled trial in adult out-of-hospital patients requiring emergency tracheal intubation. Patients were randomly assigned to either single-use or reusable metal laryngoscope blades and intubated by a senior physician or a nurse anesthetist. The primary outcome was first-pass intubation success. Secondary outcomes were incidence of difficult intubation, need for alternate airway devices, and early intubation-related complications (esophageal intubation, mainstem intubation, vomiting, pulmonary aspiration, dental trauma, bronchospasm or laryngospasm, ventricular tachycardia, arterial desaturation, hypotension, or cardiac arrest). The study included 817 patients, including 409 intubated with single-use blades and 408 with a reusable blade. First-pass intubation success was similar in both groups: 292 (71.4%) for single-use blades, 290 (71.1%) for reusable blades. The 95% confidence interval (CI) for the difference in treatments (0.3%; 95% CI -5.9% to 6.5%) did not include the prespecified inferiority margin of -7%. There was no difference in rate of difficult intubation (difference 3%; 95% CI -7% to 2%), need for alternate airway (difference 4%; 95% CI -8% to 1%), or early complication rate (difference 3%; 95% CI -3% to 8%). First-pass out-of-hospital tracheal intubation success with single-use metal laryngoscopy blades was noninferior to first-pass success with reusable metal laryngoscope blades.