Successful Tracheal Intubation Research Articles

Inspection of the nasopharynx prior to fiberoptic-guided nasotracheal intubation reduces the risk epistaxis

BackgroundVarious complications may occur during nasotracheal intubation. This may include epistaxis and damage to the nasopharyngeal airway. We tested the hypothesis that the use of fiberoptic bronchoscopy (FOB)–guided intubation is superior to endotracheal tube (ETT) obturated with an inflated esophageal stethoscope. MethodsPatients were randomly assigned to 1 of 2 groups (n=22 each): either an FOB-guided intubation group or ETT obturated with an inflated esophageal stethoscope group. After the induction of general anesthesia, patients in the FOB group received an FOB inspection through the nostril without advancement of ETT. Then, after confirming the placement of the bronchoscope tip in the trachea, the lubricated ETT was advanced via the nostril to the trachea along the bronchoscope. In the obturated ETT insertion group, the proximal opening of the ETT was blunted with an inflated esophageal stethoscope. The ETT was inserted into the selected nostril and advanced blindly into the posterior oropharynx. Then, the esophageal stethoscope was removed and tracheal intubation was performed with the bronchoscope. The number of attempts for successful tracheal intubation, the degree of difficulty during insertion, and bleeding during bronchoscopy were recorded. Another anesthesiologist, blinded to the intubation method, estimated the severity of epistaxis 5minutes after the intubation and postoperative complications. ResultsThe FOB group had significantly less epistaxis during bronchoscopy, better navigability, and fewer intubation attempts and redirections. ConclusionFiberoptic-guided nasotracheal intubation was associated with less epistaxis. It also showed better navigability and less redirection rate. Therefore, FOB as an intubation guide is superior to ETT with an inflated esophageal stethoscope when intubating a patient via the nasotracheal route.

A new option in airway management: evaluation of the TotalTrack® video laryngeal mask

Background: The TotalTrack® Video Laryngeal Mask (VLM) is a novel airway management device consisting of a disposable laryngeal mask paired with a reusable video display. Prior to the commencement of this study, there was no published literature on the performance of the TotalTrack®.Methods: The device was evaluated in sixty patients without predictors for difficult airway under general anaesthesia with neuromuscular blockade. Primary outcomes were laryngeal mask seal pressures and success of tracheal intubation through the device.Results: Insertion and ventilation was successful in 98.3% of cases. Median static leak and maximal inflation pressures of the laryngeal mask component were 32 and 40 cmH₂O respectively. Tracheal intubation through the device was successful in 95% of cases, with a mean intubation time of 9.5 s. No gastric insufflation occurred. Haemodynamic variability was found to be clinically insignificant. No significant side-effects were reported.Conclusions: In this initial study, the Tota...

Difficult Intubation Factors in Prehospital Rapid Sequence Intubation by an Australian Helicopter Emergency Medical Service

ObjectivePrehospital rapid sequence intubation (RSI) of critically ill trauma patients is a high-risk procedure that may be associated with an increased rate of severe complications such as failed intubation, failure of oxygenation, hypoxia, hypotension, or need for surgical airway. The objective of this study was to describe the factors associated with difficult intubation in prehospital RSI as defined by more than a single look at laryngoscopy to achieve tracheal intubation. MethodsThis is an observational study using prospectively collected data. ResultsFour hundred forty-three RSIs were performed. Paramedics were the initial laryngoscopist in 290 (65.5%). First-look laryngoscopy resulted in successful tracheal intubation (TI) in 372 (84.0%) (95% confidence interval, 80.3%-87.1%). Intubation was achieved on second look at laryngoscopy in 58 (13.1%). “First-pass” TI was achieved in 394 (88.9%). Overall, successful TI was achieved in 438 (98.9%) (95% confidence interval, 97.4%-99.5%). Complications occurred in 116 (26.2%), with desaturation the commonest in 77 (17.4%). ConclusionFactors associated with more than 1 look at laryngoscopy before TI included paramedic laryngoscopist and the presence of at least 1 of the following indicators: blood/vomitus in the airway, limited mouth opening, and limited neck movement. Trauma to face/neck, obese body habitus, C-spine precautions, cricoid pressure, midline stabilization, and intubation on the ground did not influence the level of difficulty encountered.

When everything failed, glidescope prevailed.

Sir, We report the successful management of an unanticipated difficult airway secondary to an asymptomatic large vallecular cyst obscuring the glottic opening using glidescope after repeated failed attempts at mask ventilation and laryngoscopy. A 70-year-old, 60 kg, American Society of Anesthesiologists (ASA) I male patient was scheduled to undergo re-exploration for persistent bleeding following transurethral resection of the prostate. The preanesthetic checkup and airway examination was unremarkable. General Anesthesia was planned in view of ongoing blood loss. Patient was shifted to the operating room and connected to the multichannel monitor (Datex-Ohmeda, Finland). Intravenous access (i.v.) was established with 18G cannula, and i.v. glycopyrrolate 0.2 mg and morphine 6 mg was given. Patient was preoxygenated with 100% oxygen for 3 min and then induced with sleep dose of thiopentone. After confirming assisted mask ventilation, i.v vecuronium (0.1 mg/kg) was given but, immediately after full muscle relaxation was achieved, absent capnography trace along with minimal movement of the chest was noticed. Guedel's airway was inserted, mask position and adequate seal reconfirmed and any leaks or equipment failure was ruled out. With failure to ventilate even now, it was decided to perform direct laryngoscopy to facilitate endotracheal intubation. Meanwhile, the anesthesia technician was also requested to bring a glidescope as the fiberoptic bronchoscope was not available. Since the patient was routinely preoxygenated with 100% oxygen, the SpO2 could be maintained at around 93% throughout till successful intubation could be accomplished. A large vallecular cyst was detected arising from the right vallecula obscuring the glottic opening entirely [Figure 1]. After two unsuccessful attempts to visualize the glottis, it was decided to use glidescope which revealed a small aperture glottic opening, distorted and displaced by the cyst. 7.0 mm cuffed oral endotracheal tube was passed beyond the cyst into the trachea and confirmed by capnogram. The cyst was then aspirated to prevent any problems at extubation. Patient was maintained on controlled ventilation using 66% nitrous oxide in oxygen with 1% isoflurane. He also received i.v 8 mg of dexamethasone following intubation. The surgery continued uneventfully for 1 h. At the end of surgery, neuromuscular blockade was reversed with 50 μg/kg of i.v neostigmine and 10 μg/kg of i.v glycopyrrolate. His trachea was extubated uneventfully. He was then shifted to postanesthesia care unit and discharged from the ward 2 days later.Figure 1: Vallecular cyst obstructing the laryngeal inletGlidescope is a new addition to the armamentarium for managing a difficult airway. Although it has been used to achieve primary airway control in anticipated, symptomatic large vallecular cyst,[1] it also helps in unanticipated difficult airway by improving the Cormack-Lehane grading and making part of the airway visible. By virtue of its inherent design of bent tip at 60°, the structures that are obscured on direct laryngoscope may be readily observed with the use of glidescope.[23] It is already established that the use of glidescope has a high success rate in both primary airway control as well as failed direct laryngoscopy.[4] The ASA difficult airway guidelines have also incorporated glidescope for improved laryngeal view and increased successful intubations.[5] This equipment use avoids multiple attempts at successful tracheal intubation. Therefore, it may be used as a tangible alternative device in a situation where tracheal placement seems to be rather difficult or impossible.

Management of Near-Complete Airway Obstruction Caused by a Vallecular Cyst in an Infant Using a Tongue Tip Traction Suture.

Airway obstruction in infants can be because of a number of airway issues, one of which is a vallecular cyst. Although uncommonly seen, the management strategy for this difficult airway can be applied to many other difficult airway cases. We report the use of a preoperative oral fiberoptic assessment of the airway, use of a tongue stitch, and manipulation of a flexible nasal fiberoptic bronchoscope to secure the airway. Keeping the patient breathing spontaneously with low-dose ketamine also facilitated successful tracheal intubation.

A good laryngeal view does not guarantee perfectly successful tracheal intubation.

Difficult tracheal intubation is the most common factor related to serious airway complications during anesthesia [1]. Difficult tracheal intubation is defined as insertion of the endotracheal tube using direct laryngoscopy that requires more than two attempts lasting more than 10 min each or that requires an alternative technique [2]. The difficult airway involves interactions among patient factors, the clinical setting, and the practitioner's skills [3]. Many alternative tools and techniques have been developed to facilitate intubation in cases of difficult direct laryngoscopy. Among these, videolaryngoscopy (VL) improves glottis visualization using either an optical or video system, which allows communication between the operator and assistants and facilitates teaching; this method is gaining popularity [4]. Recently, VL has begun to be considered as a first-line tool for airway management, rather than as a rescue tool for difficult intubation [3,5,6]. However, VL does not achieve a 100% intubation success rate, and complications have been associated with the procedure [5,7,8]. With VL, the success of intubation lies not in the view obtained, but in the ease of inserting the endotracheal tube. Instead of the Cormack-Lehane scoring system, Swann et al. [9] proposed the Fremantle score, calculated using a three-part scoring system based on the laryngeal view (full, partial, or no view), ease of endotracheal intubation (easy, modified, or unachievable), and device used. The Korean Society of Anesthesiologists should consider the use of this new scoring system and various tools for cases of difficult intubation. In this issue of the Korean Journal of Anesthesiology, Shim et al. [10] compared GlideScope® and McGrath® laryngoscopes in simulated cases of difficult intubation. They used a four-grade videoscopic view. However, they did not precisely describe the grade. In addition, a tube exchanger and vascular forceps were used instead of a rigid stylet, which can be associated with complications [8]. Although a difficult airway was simulated with an extrication collar, actual patients with difficult airways were excluded. In the simulation, the first-attempt success rates were 82.8% (GlideScope® group) and 83.8% (McGrath® group). Failed intubation with the GlideScope® was also reported in this issue of the Korean Journal of Anesthesiology [11]. There was resistance to passage of the endotracheal tube into the larynx with a conventional laryngoscope. The GlideScope® then revealed that a septum divided the subglottic area into two sections. A laryngeal mask did not provide adequate ventilation due to laryngeal edema caused by multiple intubation attempts, and the surgery was postponed. In this case, the patient failed to recall any previous difficulties with anesthesia. The preanesthetic history, chest radiography, and spirometry failed to reveal the patient's tracheal stenosis under the vocal cords. The difficulty grade of direct laryngoscopy was not described; passing the endotracheal tube was impossible due to the unusual trachea. A full view of the larynx was obtained using direct laryngoscopy and the GlideScope®. Considering these two articles, we need to keep in mind that neither the use of VL nor achievement of a laryngeal view guarantees intubation success. Accurately predicting a difficult airway remains as a cornerstone of airway management. Furthermore, considering the recognized associations between a difficult airway and patient characteristics, the patient's medical history may help to predict a difficult airway [3,12]. To avoid airway complications, anesthesiologists should be proficient in the use of a wide range of anesthetic airway techniques and alternative intubation tools and should know how to manage a failed airway, including when and how they will wake the patient in cases of difficulty [1]. In addition, for follow-up care, the anesthesiologist should inform the patient of the airway difficulty that was encountered. A written report that describes the difficult airway, including the apparent reasons for difficulty, how the intubation was finally accomplished, and the implications for future care, is recommended [3]. In conclusion, anesthesiologists should determine a strategy for a difficult intubation. They should assemble a team that can assist one another and make prompt decisions, use the most familiar and skilled tool, and record the findings in detail.

Learning and performance of endotracheal intubation by paramedical students: Comparison of GlideScope(®) and intubating laryngeal mask airway with direct laryngoscopy in manikins.

Background and Aims:GlideScope video laryngoscope (GVL) and intubating laryngeal mask airway (I-LMA) may be used to facilitate intubation and secure the airway in patients with normal and abnormal airways. The aim of this study was to evaluate whether (GVL) and (I-LMA) facilitate and improve the tracheal intubation success rate and could be learned and performed easily by paramedic students when compared with Macintosh direct laryngoscopy (DL).Methods:This study was a prospective, randomised crossover trial that included 100 paramedic students. Macintosh DL, I-LMA and GVL were tested in both normal and difficult airway scenarios. Each participant was allowed up to three intubation attempts with each device, in each scenario. The time required to perform tracheal intubation, the success rate, number of intubation attempts and of optimisation manoeuvres and the severity of dental trauma were recorded. Statistical analysis was performed using Chi-square, one-way ANOVA, or Kruskal-Wallis test as appropriate, followed by post hoc test.Results:GVL and I-LMA required less time to successfully perform tracheal intubation, showed a greater success rate of intubation, reduced the number of intubation attempts and optimization manoeuvres required and reduced the severity of dental trauma compared to Macintosh DL in both normal and difficult airway scenarios.Conclusion:GVL and I-LMA provide better airway management than Macintosh DL in both normal and difficult airway scenarios.

Tracheal extubation in children with difficult airways: a descriptive cohort analysis.

Tracheal extubation in children with difficult airways may be associated with an increased risk of perioperative adverse events. The aim of this study was to describe the exubation techniques used/ success rates/ adverse events related to tracheal extubation practices in children with difficult airways. A retrospective analysis of tracheal extubation practices in the difficult airway population over a 78-month period was performed. Difficult airway was defined as a Cormack and Lehane Grade 3 view or greater, and/or tracheal intubation requiring ≥ 3 attempts, and/or the need for an alternate device to direct laryngoscopy for successful tracheal intubation, and/or difficult mask ventilation. Reasons for difficult airway, demographic/surgical data, technique(s) for tracheal extubation, success/failure of tracheal extubation, and adverse events were recorded. A failed tracheal extubation was defined as any adverse event related to the airway occurring within 6 h of extubation requiring reintubation. A total of 519 patients were reported to have a difficult airway during this study period in a tertiary care pediatric center. Of these, 137 patients (26%) met inclusion criteria. Tracheal extubation was successfully performed in 130 patients (95%). The majority of tracheal exubations were performed without the use of additional airway adjuncts straight onto anesthesia face mask (121/137; 88%). Extubation failure occurred in seven cases (5%). Among the failed extubations, 6/7 children (85%) had evidence of severe upper airway obstruction and were <10 kg in weight. Of these children, one child required emergency tracheostomy, and two children (one with tracheal stenosis and other with spinal muscular atrophy) suffered from hypoxemic cardiac arrest and anoxic brain damage, respectively, and eventually died. In the studied population of children with difficult airways handled in a tertiary center environment, the majority of tracheal extubations could be performed without the use of airway adjuncts. In a minority of patients, tracheal extubation was associated with severe adverse outcomes.

Comparison of Tracheal Intubation Using the Storz's C-Mac D-blade(TM) Video-Laryngoscope Aided by Truflex(TM) Articulating Stylet and the Portex(TM) Intubating Stylet.

Background:Tracheal intubation using Storz’s C-Mac D-bladeTM videolaryngoscope is associated with difficult negotiation of the tracheal tube into the glottis due to steep angulation of its blade.Objectives:In this study, we hypothesized that TruflexTM articulating stylet with its ability to dynamically tailor the ETT shape to patients’ oropharyngeal anatomy would be better suited to the D-blade angulation and ease tracheal intubation compared to PortexTM intubation stylet.Patients and Methods:Following approval by the Ethical Issues Committee and informed consent, 218 ASA I and II patients of either sex were enrolled in this interventional, single-blind, randomized controlled trial. Tracheal intubation was performed following a uniform general anesthetic technique using the Storz’s C-Mac D-bladeTM videolaryngoscope aided by either TruflexTM articulating stylet or the PortexTM intubation stylet by an experienced anesthesiologist. The outcome measures included success or failure to intubate in the first attempt, total intubation time, hemodynamic disturbances, trauma if any and user satisfaction.Results:The number of patients in whom intubation was successful in the first attempt was significantly higher by using Truflex™ articulating stylet (99.1%) compared to PortexTM intubation stylet (90.0%; P-Value = 0.003). User satisfaction grade was significantly better while using TruflexTM articulating stylet (8.5 ± 0.88) compared to the PortexTM intubation stylet (8.23 ± 0.99; P-Value = 0.035). We did not observe any significant difference in total intubation time, hemodynamic disturbances or trauma.Conclusions:Storz’s C-Mac D-bladeTM videolaryngoscope provides grade I Cormack and Lehane’s glottic view in 99.1% patients. First attempt successful tracheal intubation and user satisfaction significantly improved by TruflexTM articulating stylet compared to the PortexTM intubation stylet.

Parker Flex-It stylet is as effective as GlideRite Rigid stylet for orotracheal intubation by Glidescope.

Objectives:To evaluate Parker Flex-It stylet as an alternative to GlideRite Rigid stylet to aid tracheal intubation with the Glidescope.Methods:This prospective randomized trial was conducted at King Abdulaziz University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia between May and December 2014. Sixty American Society of Anesthesiologists I-II patients were randomly assigned to one of 2 equal groups receiving intubation by Glidescope using either GlideRite Rigid stylet (Group GS) or Parker Flex-It stylet (Group PS). The total intubation time, ease of intubation, incidences of successful intubation at first attempt, number of intubation attempts, use of optimization maneuvers, and possible complications were recorded.Results:No significant differences between both groups regarding the total intubation time (p=0.08) was observed. Intubation was significantly easier in group PS compared with group GS as measured by visual analogue scale (p=0.001) with no significant differences between the groups regarding the rate of successful tracheal intubation from first attempt (p=0.524). However, the number of attempts at intubation and usage of external laryngeal manipulation were similar in both groups (p>0.05). The incidence of sore throat, dysphagia, hoarseness, and trauma were significantly higher in group GS (p<0.05).Conclusion:Parker Flex-It stylet is as effective as GlideRite Rigid stylet when used by experienced operators in patients with normal airways using Glidescope; however, it is easier and less traumatic.

First-pass intubation success rate during rapid sequence induction of prehospital anaesthesia by physicians versus paramedics

Endotracheal intubation is a frequently performed procedure for securing the airway in critically injured or ill patients. Performing prehospital intubation may be challenging and intubation skills vary. We reviewed the first-attempt tracheal intubation success rate in a Dutch prehospital setting. We studied our database for all intubations performed by helicopter emergency medical services (HEMS) physicians, HEMS nurse and ambulance paramedics under HEMS supervision between January 2007 and July 2012. The primary outcome was success rate, number of intubation attempts and alternative airway procedures. In all, 1399 patients were in need of a secured airway. In 571 (40.8%) of these cases, ambulance paramedics made a first intubation attempt under HEMS supervision. If necessary, rapid sequence induction medication was administered. In comparable patient groups, the first intubation success rate was significantly lower in ambulance paramedics compared with helicopter physicians (46.4 vs. 84.5%, P<0.0001). The overall physician intubation success rate was 98.4% after one or more intubation attempts. In 19 cases, a surgical airway was created and in three cases an alternative ventilation method was used. Prehospital intubations had a significantly higher success rate when performed by helicopter physicians. We promote a low threshold for HEMS deployment in cases of a potentially compromised airway.

In a difficult access scenario, supraglottic airway devices improve success and time to ventilation.

The success of tracheal intubation (TI) is unacceptably low in unconventional positions. Supraglottic airway devices (SAD) have become an important alternative. An airway manikin was placed in a car, simulating an entrapped motor vehicle accident victim. The rescuer only had access through the driver's door. Participants were (n = 25) anaesthesiologists with experience in prehospital emergency medicine. They attempted to secure the airway by TI or an SAD (Ambu AuraOnce, iGel, laryngeal tube) in a random sequence. Performance was compared using the Wilcoxon signed-rank test. P values less than 0.05 were considered statistically significant. Fastest effective ventilation was achieved with iGel (11.5 ± 6.9 s, P < 0.001), followed by a laryngeal mask (15.1 ± 5.6 s, P < 0.001) and a laryngeal tube (17.6 ± 5.3 s, P < 0.001); TI was the slowest (42.8 ± 23.9 s, comparator). iGel (P < 0.001) and laryngeal mask (P = 0.01) also significantly outperformed the laryngeal tube. First ventilation was achieved significantly faster with SADs compared with TI. Success rates were also higher when using SADs.

Videolaringoscopios: ¿la solución para el manejo de la vía aérea difícil o una estrategia más? Revisión no sistemática

IntroductionDifficult airway management remains a challenge and is a pillar of anesthesia training. At present, unsuccessful management of the difficult airway is a leading cause of complications in the practice of anesthesia, something that has led to regular updates to the management algorithms and the development of new technologies. ObjectivesTo review the current state of videolaryngoscopy and its impact on difficult airway management. MethodsWith the keywords videotape recording; laryngoscopy; airway management; intubation, intratracheal; obesity; anesthesia. A non-systematic review in the following databases was conducted: (PubMed/Medline, SciElo, LILACS). ResultsVideolaryngoscopes are a new technology for the management of difficult airways that so far have not replaced the standard airway management algorithm devices. Its main impact is better visualization of the laryngeal structures. However, there are still controversies regarding the ease and success of tracheal intubation. Evidence of its usefulness in difficult airway management is weak. ConclusionKnowledge of these devices and their limitations is an alternative in difficult airway scenario, but its real value and safety for the patient is still not defined and continues to be researched.

Videolaryngoscopes: The solution for difficult airway management or just another strategy? Non-systematic review

IntroductionDifficult airway management remains a challenge and is a pillar of anesthesia training. At present, unsuccessful management of the difficult airway is a leading cause of complications in the practice of anesthesia, something that has led to regular updates to the management algorithms and the development of new technologies. ObjectivesTo review the current state of videolaryngoscopy and its impact on difficult airway management. MethodsWith the keywords Videotape Recording; Laryngoscopy; Airway Management; Intubation; Intratracheal; Obesity; Anesthesia. A non-systematic review in the following databases was conducted: Pubmed/Medline, SciElo, LILACS). ResultsVideolaryngoscopes are a new technology for the management of difficult airways that so far have not replaced the standard airway management algorithm devices. Its main impact is better visualization of the laryngeal structures. However, there are still controversies regarding the ease and success of tracheal intubation. Evidence of its usefulness in difficult airway management is weak. ConclusionKnowledge of these devices and their limitations is an alternative in difficult airway scenario, but its real value and safety for the patient is still not defined and continues to be researched.

The reflective intubation manoeuvre increases success rate in moderately difficult direct laryngoscopy: A prospective case-control study.

Reflective intubation is a recently described technique to facilitate tracheal intubation. The aim of the study was to assess success rate of reflective intubation in patients undergoing tracheal intubation and to correlate its application with laryngeal visibility. A prospective case-control study. Operating theatre suite of a university hospital. One hundred randomly selected patients undergoing elective surgery who required tracheal intubation as part of standard anaesthesia care. All patients underwent an initial intubation attempt using conventional direct laryngoscopy. Successfully intubated patients formed group E (easy), and the remaining patients underwent a single reflective intubation attempt. Patients with successful reflective intubation formed group M (moderate). The remaining patients underwent tracheal intubation using a suitable alternative intubation technique (group D, difficult). Primary outcomes were the success rate and time to successful intubation. Laryngeal visibility scores, changes in arterial oxygen saturation and incidence of sore throat were secondary outcomes. Forty-six patients underwent successful tracheal intubation using conventional laryngoscopy (group E), 42 patients presented moderate difficulty (group M) and 12 patients required alternative intubation techniques (group D). Reflective intubation was successful in 78% of patients in the 'noneasy' subgroup, but was unsuccessful in 22%. Intubation times were 9 ± 3 (group E), 15 ± 9 (group M) and 46 ± 38 s (group D). Oxygen saturation was comparable in all patients. Sore throat occurred significantly more often in group D. Reflective intubation proved to be successful in moderately difficult intubation conditions (Cormack and Lehane classes 2 and 3a). Reflective intubation represents a very useful first-line methodological extension of direct laryngoscopic tracheal intubation.

Does Video Laryngoscopy Offer Advantages over Direct Laryngoscopy during Cardiopulmonary Resuscitation?

Interruption of chest compressions should be minimized because of its negative effects on survival. This randomized, controlled, cross-over study aimed to analyze the effectiveness of Macintosh, Miller, McCoy and McGrath laryngoscopes during with or without chest compressions in the scope of a simulated cardiopulmonary resuscitation scenario. The time required for successful tracheal intubation, number of attempts, dental trauma severity and the need for optimization manoeuvres were recorded during cardiopulmonary resuscitation with and without chest compressions. The experience with computer games during the last 10 years were asked to the participants and recorded. McCoy laryngoscope yielded the shortest time for successful tracheal intubation both in the presence of and without chest compressions. During the use of McCoy laryngoscopes, fewer tracheal intubation attempts, lower incidence of dental trauma and lower visual analogue scale scores on the ease of intubation were recorded. Participants who are experienced computer game players using Macintosh, McCoy and McGrath achieved successful tracheal intubation in a significantly shorter time during resuscitation without chest compressions. Dental trauma incidence and number of tracheal intubation attempts did not show any significant difference between the four laryngoscopes being related to the rate of playing computer games. McGrath video laryngoscopes do not appear to have advantages over direct laryngoscopes for securing a smooth and successful tracheal intubation during rhythmic chest compressions. We believe that as McCoy laryngoscope provided tracheal intubation in a shorter time and with fewer attempts, this laryngoscope may increase the success rate of resuscitation.

Neuromuscular blockade improves first-attempt success for intubation in the intensive care unit. A propensity matched analysis.

The use of neuromuscular blocking agents (NMBAs) has been shown to be valuable in improving successful tracheal intubation in the operating room and emergency department. However, data on NMBA use in critically ill intensive care unit (ICU) patients are lacking. Furthermore, there are no data on NMBA use with video laryngoscopy. To evaluate the effect of NMBA use on first-attempt success (FAS) with tracheal intubation in the ICU. Single-center observational study of 709 consecutive patients intubated in the medical ICU of a university medical center from January 1, 2012 to June 30, 2014. Data were collected prospectively through a continuous quality improvement program on all patients intubated in the ICU over the study period. Data relating to patient demographics, intubation, and complications were analyzed. We used propensity score (propensity to use an NMBA) matching to generate 5,000 data sets of cases (failed first intubation attempts) matched to controls (successful first attempts) and conditional logistic regression to analyze the results. There were no significant differences in patient demographics, except median total difficult airway characteristics were higher in the non-NMBA group (2 vs. 1, P < 0.001). There were significant differences in the sedative used between groups and the operator level of training. More patients who were given NMBAs received etomidate (83 vs. 35%) and more patients in the non-NMBA group received ketamine (39 vs. 9%) (P < 0.001). The FAS for NMBA use was 80.9% (401/496) compared with 69.6% (117/168) for non-NMBA use (P = 0.003). The summary odds ratio for FAS when an NMBA was used from the propensity matched analyses was 2.37 (95% confidence interval, 1.36-4.88). In the subgroup of patients intubated with a video laryngoscope, propensity-adjusted odds of FAS with the use of an NMBA was 2.50 (1.43-4.37; P < 0.001). There were no differences in procedurally related complications between groups. After controlling for potential confounders, this propensity-adjusted analysis demonstrates improved odds of FAS at intubation in the ICU with the use of an NMBA. This improvement in FAS is seen even with the use of a video laryngoscope.

Randomized comparison of experts and trainees with nasal and oral fibreoptic intubation in children less than 2 yr of age

We hypothesized that the time to successful fibreoptic tracheal intubation through the nasal route would be faster than the oral route for both experts and trainees in children <2 yr of age. One hundred children, 24 months and under in age, were randomized to an operator (expert or trainee), and route (nasal or oral) for fibreoptic tracheal intubation. Three separate times were then measured: (i) time to first glottic view, (ii) time to carinal view, and (iii) total time to successful tracheal intubation. The number of attempts made, manoeuvres needed to obtain an adequate laryngeal view, and manoeuvres for tracheal tube passage were also recorded. Time to successful tracheal intubation was significantly faster for experts than trainees. There was no difference in the time to tracheal intubation between the nasal and oral routes for experts. In trainees, intubation times were shorter for the nasal route-median (inter-quartile range) time (s) to carinal view was 35 (27-63) for the nasal route vs 59 (38-94) for the oral route (P=0.03), and the median time to successful tracheal intubation were 62 (49-122) vs 117 (61-224), P=0.05, for the nasal and oral routes, respectively. For trainees, the oral route required a greater number of airway manoeuvres for adequate laryngeal views and passage of the tracheal tube compared with the nasal route. For clinicians with less experience in using paediatric bronchoscopes, fibreoptic tracheal intubation through the nasal route may be a more straightforward process than the oral route in children <2 yr of age. NCT02029300 (www.clinicaltrials.gov).

Air leak with intact cuff inflation system: A case report with brief review of literature.

Sir, Tracheal re-intubation because of air leak after a successful tracheal intubation is not very uncommon in anaesthesia practice. The most common illustrated causes for air leaks are related to a defect in the cuff, inflation tube/lumen, pilot balloon, or the spring loaded inflation valve. Here, we report an unexpected product quality compromise leading to appreciable air leak without a defect in cuff inflation system. The trachea of a 38-year-old lady posted for elective transsphenoidal excision of pituitary adenoma was successfully intubated with a 7 mm internal diameter disposable flexometallic endotracheal tube (ETTfm) (Sterimed™) and was secured with elastic adhesive plaster at lip line corresponding to 21 cm on the ETTfm tube. A few minutes later while positioning the patient, we noticed audible air leak from the mouth. Hence, we followed a stepwise approach to ascertain and fix the cause. In the first step, we pushed 2 ml air (in addition to 5 ml air used to inflate the cuff initially) and found that the pilot balloon was holding the air that ensured an intact cuff and a competent inflation valve. However, the air leak was still audible from patient's oral cavity with each mechanised positive pressure breath. In the next step, we ascertained the correct position of tracheal tube with check laryngoscopy which confirmed that the entire cuff is below the vocal cord. In the final step, we presumed that the tube may be too small for the trachea of the patient. However auscultation over trachea was negative; but to give the benefit of doubt we re-intubated the patient with a new ETTfm tube and with this, there was no air leak. After uneventful completion of surgery and subsequent extubation, we re-examined and compared both the ETTsfm to localise the cause of air leak. On careful physical examination, we found a small defect near the insertion point of the inflation tube in the first ETTfm [Figure 1], suggesting air leak from the wall of the tube despite the pilot balloon appearing to be firmly inflated. Figure 1 The red in colour arrow pointing toward the oval defect in the wall of the flexometallic tube. The flexometallic endotracheal tube is straightened to make the defect more appreciable Normally, cuff leak or leak around the cuff can be identified by looking at pilot balloon, palpation of the cuff over suprasternal space, auscultation over trachea and bubbles coming out from the oral and nasal cavity if secretions are present. However, the leak from the wall of the ETTfm at the insertion point of pilot balloon is difficult to identify unless we look for it because the junction is situated 18 cm from tip of the ETTfm just behind the incisor and possibly much above the accumulated secretion if any, to form the bubbles. Literature search illustrated few more case reports implicating improper fixation of the tube by adhesive plaster,[1] repeated use and attempt to remove the adhesive plaster,[2] bitten notch on re-sterilised tube[3] and low product quality compliance[4] as the cause of unexpected air leak from after tracheal intubation. In all these reports, the recommended in vitro test failed to detect such type of occult leak.[5] However, one author reported that such occult leak can be detected if, the tube was examined by flexing it opposite to its natural curve immersed in a bowl of water.[6] Our case report along with the discussed literature re-affirms that air leaks may be present in all types of ETT (both flexometallic and polyvinyl chloride) irrespective of their trade mark. The structural defect leading to air leak may be there in a newly opened ETT or may be caused by repeated use of re-sterilised tube. The small cuts and holes on the convex surface of the ETTfm and near the entry point of the inflation tube usually go undetected by routine in vitro test. Considering the fact that a small air leak at the beginning of the surgery may become larger leading to dangerous inadequate ventilation, an ideal solution for this type of problem would be use of a magnifying glass to verify structural integrity of cuff, insertion point and pilot balloon. However, as it is practically not possible to check each and every tube using a magnifying glass, such problems do occur irrespective of manufacturer. Hence, anaesthesiologist should be aware of such possibilities, and this should be kept in the mind as a diagnosis of exclusion, for which the best solution is change of the tube. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Successful tracheal intubation in a patient with trismus using the X blade and McGrath videolaryngoscope

SummaryThe McGrath® MAC videolaryngoscope is designed for difficult airways and several standard blades are available. In July 2014, the X blade, with a more acute anterior curvature and slimmer profile than standard blades, entered the Japanese market. We report a case of successful tracheal intubation in a patient with trismus using the X blade. A 59‐yr‐old female presented for right upper lobectomy due to suspected lung cancer. After induction of general anaesthesia, mouth opening was limited to only 15 mm, possibly due to a temporomandibular disorder. We were able to insert the X blade without difficulty and visualise the glottis. Advancing the tracheal tube through the glottis was difficult, so we inserted a catheter through the tracheal tube. We could then advance the tracheal tube over the catheter into the trachea. Combination of the X blade and an introducer may be an option when faced with a difficult airway, especially due to trismus.