Technique Of Endotracheal Intubation Research Articles

Articulating Video Stylet Compared to Other Techniques for Endotracheal Intubation in Normal Airways: A Simulation Study in Consultants with No Prior Experience

Simulation for airway management allows for acquaintance with new devices and techniques. Endotracheal intubation (ETI), most commonly performed with direct laryngoscopy (DL) or video laryngoscopy (VLS), can be achieved also with combined laryngo-bronchoscopy intubation (CLBI). Finally, an articulating video stylet (ProVu) has been recently introduced. A single-center observational cross-sectional study was performed in a normal simulated airway scenario comparing DL, VLS-Glidescope, VLS-McGrath, CLBI and ProVu regarding the success rate (SR) and corrected time-to-intubation (cTTI, which accounts for the SR). Up to three attempts/device were allowed (maximum of 60 s each). Forty-two consultants with no experience with ProVu participated (15 ± 9 years after training completion). The DL was significantly faster (cTTI) than all other devices (p = 0.033 vs. VLSs, and p < 0.001 for CLBI and Provu), no differences were seen between the two VLSs (p = 0.775), and the VLSs were faster than CLBI and ProVu. Provu had a faster cTTI than CLBI (p = 0.004). The DL and VLSs showed similar SRs, and all the laryngoscopes had a higher SR than CLBI and ProVu at the first attempt. However, by the third attempt, the SR was not different between the DL/VLSs and ProVu (p = 0.241/p = 0.616); ProVu was superior to CLBI (p = 0.038). In consultants with no prior experience, ProVu shows encouraging results compared to DL/VLSs under simulated normal airway circumstances and further studies are warranted.

Anesthesia management in a pediatric patient with complicatedly difficult airway: A case report

Reports on perioperative anesthesia management in pediatric patients with difficult airways are scarce. In addition to relatively more difficulties in the technique of endotracheal intubation, the time for manipulation is restricted compared to adults. Securing the airways safely and avoiding the occurrence of hypoxemia in these patients are of significance. A 9-year-old boy with spastic cerebral palsy, severe malnutrition, thoracic scoliosis, thoracic and airway malformation, laryngomalacia, pneumonia, and epilepsy faced the risk of anesthesia during palliative surgery. After a thorough preoperative evaluation, a detailed scheme for anesthesia and a series of intubation tools were prepared by a team of anesthesiologists. Awake fiberoptic intubation is the widely accepted strategy for patients with anticipated difficult airways. Given the age and medical condition of the patient, we kept him sedated with spontaneous breathing during endotracheal intubation. The endotracheal intubation was completed on the second attempt after the failure of the first effort. Fortunately, the surgery was successful without postoperative complications. Dealing with difficult airways in the pediatric population, proper sedation allows time to intubate without interrupting spontaneous breathing. The appropriate endotracheal intubation method based on the patient's unique characteristics is the key factor in successful management of these rare cases.

Does Practitioner Experience Affect Intraocular Pressure After Endotracheal Intubation?

Intraocular pressure (IOP) may decrease or increase during general anesthesia, depending on various factors. This study aimed to investigate theeffects of the level of provider training period on post-intubation IOP values and hemodynamic response. This study was a cross-sectional observational study. Before inclusion in the study, informed consent was obtained from all participants. The study was approved by the localethical committee. The study included 120 adult patients, both sexes, aged between 18 and 65, with physical statuses according to the American Society of Anesthesiologists (ASA) I or II, Mallampati score I. The research included 120 anesthesiologist resident doctors who received their training in our clinic. In this study, anesthesiology resident doctors were divided into three separate seniority groups (group 1, less than one-year residents in anesthesiology who had performed fewer than 10 intubations; group 2, one- to three-year residents; and group 3, more than three-year residents). After receiving a standard intravenous induction, direct laryngoscopy and endotracheal intubation techniques were performed. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and IOP were measured and recorded before pre-induction (T1), the first minute after induction (T2), and the first minute after laryngoscopy and intubation (T3). There was nostatistically significant difference (p > 0.05) between groups in the values of IOP, SBP, DBP, and HR measured at T1, T2, and T3. Measurements at T1, T2, and T3 were similar in all three groups. Comparisons within the groups revealed that IOP values at all measurement times (T1, T2, and T3)were different from each other in less than three-year resident groups. This difference was statistically significant (p < 0.001). The measurement values at T2 were the lowest and T3 were the highest in less than three-year resident groups. There was a significant increase in IOP after endotracheal intubation (T3) compared to baseline levels (T1) in less than three-year resident groups. IOP values at T2 were also significantly lower than the values at T1 and T3(p < 0.001) in the more than three-year resident group (group 3). However, when we compared IOP measurements at T1 and T3 among themselves in the more than three-year resident group, no significant difference was found (p > 0.05). This study showed that endotracheal intubation in general anesthesia practice is performed most effectively by resident doctors with more than three years of anesthesiology training, without changing the IOP value.

Endotracheal Intubation Using a Flexible Intubation Endoscope As a Standardized Model for Safe Airway Management in Swine.

Endotracheal intubation is often a basic requirement for translational research in porcine models for various interventions that require a secured airway or high ventilation pressures. Endotracheal intubation is a challenging skill,requiring a minimum number of successful endotracheal intubations to achieve a high success rate under optimal conditions, which is often unachievable for non-anaesthesiology researchers. Due to the specific porcine airway anatomy, a difficult airway can usually be assumed. The impossibility of establishing a secure airway can result in injury, adverse events, or death of the laboratory animal. Using a prospective, randomized, controlled evaluation approach, it has been shown that fiberoptic-assisted endotracheal intubation takes longer but has a higher first-pass success rate than conventional intubation without causing clinically relevant drops in oxygen saturation. This model presents a standardized regimen for endoscopically guided endotracheal intubation, providing a secured airway, especially for researchers who are inexperienced in the technique of endotracheal intubation via direct laryngoscopy. This procedure is expected to minimize animal suffering and unnecessary animal losses.

Blind bougie first pass success endotracheal intubation process: An out-of-hospital case report

The blind bougie technique is performed when the epiglottis is visible to the intubator, but the vocal cords cannot be seen (Grade III Cormack-Lehane view). The blind bougie technique for endotracheal intubation is not routinely performed by Critical Care Paramedics for a failed intubation in the prehospital setting. However, at Hamad Medical Corporation Ambulance Service in the State of Qatar, the blind bougie technique is included in their failed airway clinical practice guidelines. This case report aims to describe the rapid sequence induction for intubation process and endotracheal tube placement in an adult trauma patient, presenting with a difficult airway, using the blind bougie technique in the out-of-hospital setting. A 35-year-old male patient was ejected from an all-terrain vehicle following a high-speed accident in the desert. The patient sustained an isolated head injury. Based on the patient’s clinical presentation, he required immediate endotracheal intubation for maintenance and protection of his airway prior to rapid transport to definitive care. Predictors of difficult airway were calculated. Using the blind bougie technique, endotracheal intubation was performed with first pass success. It is recommended that emergency medical services include the blind bougie technique of endotracheal intubation among their difficult airway procedures.

Maintenance of basic endotracheal intubation skills with direct or video-assisted laryngoscopy: A randomized crossover follow-up study in inexperienced operators.

BackgroundLaryngoscopy is a difficult skill to acquire and maintain and even more so by less frequent users. Numerous studies have compared limitations of direct laryngoscopic (DL) and video‐assisted laryngoscopic (VL) techniques for endotracheal intubation in different scenarios, but individual retention over time of intubation skills with either technique has, to our knowledge, never been reported. The primary aim of this study was to evaluate to what extent recently acquired basic skills of endotracheal intubation, based on DL or VL, are being maintained over time by inexperienced operators.MethodsThis randomized crossover follow‐up study was designed to compare endotracheal intubation with direct (McIntosh blade) versus video‐assisted (hyperangulated blade) laryngoscopy by 20 undergraduate medical students in identical manikins three months after brief basic intubation training with no further intubation practice.ResultsNo significant differences in skills retention were found between DL and VL regarding the time for successful intubation or number of adverse events. However, the first intubation was significantly slower regardless of the technique compared with the last one three months earlier. Furthermore, DL was slower and associated with more incidents of esophageal intubation and dental manipulation than was VL.ConclusionsAlthough basic intubation skills seem to be similarly well maintained over time regardless of the laryngoscopic technique, endotracheal intubation with VL by inexperienced operators is faster and associated with fewer adverse events than is DL after a three‐month period with no further intubation training.

Airway management in the adult patient with an unstable cervical spine.

The ideal airway management of patients with unstable spinal injury presents a perennial challenge for anaesthesiologists. With competing interests, potentially catastrophic complications, and a scarcity of evidence to support common practices, it is an area rich with dogma and devoid of data. This review seeks to highlight recent evidence that improves our assurance that what we do to manage the airway in the unstable cervical spine is supported by data. The increasing range of available technology for intubation provides important opportunities to investigate the superiority (or otherwise) of various techniques - and a chance to challenge accepted practice. Long-held assumptions regarding spinal immobilisation in the context of airway management may require refinement as a true base of evidence develops. Video laryngoscopy may replace direct laryngoscopy as the default technique for endotracheal intubation in patients with suspected or confirmed spinal instability. Immobilisation of the unstable cervical spine, manually or with rigid cervical collars, is increasingly controversial. It may be that hard collars are used in specific circumstances, rather than as universal precaution in the future.There are no recent data of significantly high quality to warrant wholesale changes to recommended airway management practice and in the absence of new information, limiting movement (in the suspected or confirmed unstable cervical spine) remains the mainstay of clinical practice advice.

Comparison of blind intubation and a smartphone-based endoscope-assisted intubation in rabbits

ObjectiveTo compare between blind and smartphone-based endoscope-assisted techniques for endotracheal intubation in rabbits. Study designProspective clinical study. AnimalsA total of 34 rabbits. MethodsRabbits were assigned to four groups: intubation by a veterinary anesthesiologist (VA) or an exotic pet medicine specialist (EPS) using blind or endoscope-assisted techniques. Propofol dose, number of attempts until successful intubation, total time for intubation, duration of the successful attempt and occurrence of lingual cyanosis/laryngeal lesions were recorded. Data were analyzed by t test, Wilcoxon–Mann–Whitney U test or chi-square test. Pearson correlation for body weight was performed. ResultsThe success rate of blind intubation was 88.9% and 77.8% for VA and EPS, respectively. Propofol dose, total and median number of attempts, total time for intubation and duration of the successful attempt were 3.1 (0–6.2) mg kg–1, 19, 2 (1–5), 79 ± 65 and 30 ± 20 seconds for VA and 1.5 (0–4.5) mg kg–1, 24, 3 (1–5), 136 ± 92 and 38 ± 16 seconds for EPS. The success rate of endoscope-assisted intubation was 87.5% for both operators. Propofol dose, total and median number of attempts, total time for intubation and duration of the successful attempt were 2.5 (1.3–7.4) mg kg–1, 22, 3 (1–5), 170 (65–368) and 46 (22–150) seconds for VA and 3.2 (0–6) mg kg–1, 11, 1 (1–4), 56 (27–432) and 55 (26–79) seconds for EPS. VA performed blind intubation more quickly, propofol dose was lower and cyanosis was less frequent than in the endoscope-assisted group. Conclusions and clinical relevanceBoth techniques were reliable for rabbit endotracheal intubation. Best results were achieved when the operator was experienced in the technique. The smartphone-based endoscope is a useful aid for rabbit intubation.

Comparison of the Effects of Endotracheal Intubation of Wistar Rats Using the Conventional Technique vs. a New Modified Technique Using a 3D Mouth-Piece

Aims Endotracheal intubation in rats is challenging due to the difficult anatomical characteristics of the airway. The success rate at first attempt is low and airway damage is a common complication. We aimed to compare and evaluate the conventional intubation method with a modified procedure using an inclined plate, headlamp (700-Lumen), and 3D mouth-piece designed with a 20° curvature. Both techniques were conducted by laboratory personnel with and without previous experience in airway management of laboratory rats. Material and methods In this study, we used 36 Wistar rats of both genders. Three groups of laboratory personnel (anesthesiologists, medical students, and laboratory technicians) performed both endotracheal intubation techniques, i.e., blind intubation at supine position and endotracheal intubation at 70° supine position with a 3D mouth-piece and direct illumination of the glottis. Results The modified technique had a significantly higher success rate and shorter procedure duration. Moreover, there was no significant difference in the procedure duration between personnel with and without previous training in airway management. Conclusion Previous knowledge and experience in airway management are required when performing conventional endotracheal intubation; moreover, its success rate is low. Contrastingly, using proper instruments and the 3D mouth-piece facilitated easier and quicker airway management regardless of previous experience.

Three Airway Management Techniques for Airway Decontamination in Massive Emesis: A Manikin Study.

IntroductionEmesis occurs during airway management and results in pulmonary aspiration at rates of 0.01% – 0.11% in fasted patients undergoing general anesthesia and 0% – 22% in non-fasted emergency department patients. Suction-assisted laryngoscopy and airway decontamination (SALAD) involves maneuvering a suction catheter into the hypopharynx, while performing laryngoscopy and endotracheal intubation. Intentional esophageal intubation (IEI) involves blindly intubating the esophagus to control emesis before endotracheal intubation. Both are previously described techniques for endotracheal intubation in the setting of massive emesis. This study compares the SALAD and IEI techniques with the traditional approach of ad hoc, rigid suction catheter airway decontamination and endotracheal intubation in the setting of massive simulated emesis.MethodsSenior anesthesiology and emergency medicine (EM) residents were randomized into three trial arms: the traditional, IEI, or SALAD. Each resident watched an instructional video on the assigned technique, performed the technique on a manikin, and completed the trial simulation with the SALAD simulation manikin. The primary trial outcome was aspirate volume collected in the manikin’s lower airway. Secondary outcomes included successful intubation, intubation attempts, and time to successful intubation. We also collected pre- and post-simulation demographics and confidence questionnaire data.ResultsThirty-one residents (21 anesthesiology and 10 EM residents) were randomized. Baseline group characteristics were similar. The mean aspirate volumes collected in the lower airway (standard deviation [SD]) in the traditional, IEI, and SALAD arms were 72 (45) milliliters per liter (mL), 100 (45) mL, and 83 (42) mL, respectively (p = 0.392). Intubation success was 100% in all groups. Times (SD) to successful intubation in the traditional, IEI, and SALAD groups were 1.69 (1.31) minutes, 1.74 (1.09) minutes, and 1.74 (0.93) minutes, respectively (p = 0.805). Overall, residents reported increased confidence (1.0 [0.0–1.0]; P = 0.002) and skill (1.0 [0.0–1.0]; P < 0.001) in airway management after completion of the study.ConclusionThe intubation techniques provided similar performance results in our study, suggesting any one of the three can be employed in the setting of massive emesis; although this conclusion deserves further study. Residents reported increased confidence and skill in airway management following the experience, suggesting use of the manikin provides a learning impact.

Management of Laryngotracheal Stenosis: A 10-Year Study on the Role of Stents

Abstract Introduction Laryngotracheal stenosis (LTS) is mostly due to road traffic accidents, prolonged intubation, and tracheostomy. Objectives This study focused on a 10-year experience on the role of stents in the management of LTS in a tertiary referral hospital. The aims of this study were to study the internal dimensions of the subglottis and upper trachea in the Indian adult population; to study the mucosal response to injury to the subglottis and the trachea; and to develop an ideal stent for use in LTS in a rabbit model. Materials and Methods The authors have been treating patients with LTS since 2000. The present study deals with the experience of 82 cases of LTS treated over the past 10 years using stents as well as surgical procedures such as Shiann Yann Lee tracheoplasty and tracheal resection and anastomosis. The work also involved a focused research on LTS using rabbits by inducing injury to the mucosa of the upper trachea and subglottis and histological study of the response to injury. The study led to the development of new indigenous stent for use in rabbits to prevent LTS. This stent has been patented. Statistical Analysis The study of the subglottis and upper tracheal discussion have been analyzed and proved that the dimension in the Indian adult population was smaller than in Caucasians. The mucosal inflammation following injury at the subglottis and upper trachea can be reversed by topical application of triamcinolone, which was better than Mitomycin on statistical analysis. Results The quality of life measured after treatment of LTS using stents and other methods of reconstructive surgery has given an overall benefit of 90% with no mortality. Conclusion LTS is a preventable disease. It can be prevented by proper care of patients in ICU and correct technique of endotracheal intubation and tracheostomy. Further, it can be avoided using medications during extubation and proper decannulation protocol. The silastic “T” tube stents are useful to improve the quality of life in these patients.

A single-centre, randomised controlled feasibility pilot trial comparing performance of direct laryngoscopy versus videolaryngoscopy for endotracheal intubation in surgical patients

IntroductionMost trials comparing effectiveness of laryngoscopy technique use surrogate endpoints. Intubation success is a more appropriate endpoint for comparing effectiveness of techniques or devices. A large pragmatic clinical trial powered for intubation success has not yet been performed.MethodsWe tested the feasibility of a randomised controlled trial to compare the performance of direct laryngoscopy versus videolaryngoscopy for endotracheal intubation. The trial was conducted in the Department of Adult and Emergency Anaesthesia at the Auckland City Hospital, New Zealand. Patients over 18 years who required endotracheal intubation and were not known or predicted to be difficult to bag-mask ventilate were eligible for the study. Patients were excluded if they required rapid sequence induction, fibreoptic intubation or were unable to consent due to language barriers or cognitive impairment.Patients were permuted block randomised in groups of 8 to either direct laryngoscopy (DL) or videolaryngoscopy (VL) for the technique of endotracheal intubation. Patients were blinded to laryngoscopic technique; the duty anaesthetist, outcome assessors and statistician were unblinded.Feasibility was assessed on recruitment rate, adherence to group assignment and data completeness. Primary outcome was first-pass success rate, with secondary outcomes of time to intubation (seconds), Intubation Difficulty Score and complication rate.ResultsOne hundred and six patients were randomised and 100 patient results were analysed. Completed data from patients randomised to the DL group (n = 49) was compared with those in the VL group (n = 51). Group adherence and data completeness were 100% and 97%, respectively. First-pass success rate was 83.7% in the direct laryngoscopy group and 72.5% in the videolaryngoscopy group (p = 0.18). Median time to intubation was significantly shorter for direct laryngoscopy when compared to videolaryngoscopy (34 s v 43 s, p = 0.038). Complications included mucosal trauma and airway bleeding which are recognised complications of endotracheal intubation.ConclusionA large, pragmatic, multicentre, randomised controlled trial comparing the relative effectiveness of direct laryngoscopy and indirect videolaryngoscopy is feasible.Trial registrationAustralian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12615001267549

Capnography-guided Endotracheal Intubation as an Alternative to Existing Intubation Methods in Rabbits.

Rabbits provide a unique challenge for routine endotracheal intubation in clinical practice because of various distinctive anatomic and physiologic features. Many previously proposed methods for endotracheal intubation in rabbits are limited by several factors, including the needs for expensive equipment and high levels of technical expertise. We evaluated capnography for its effectiveness in assisting endotracheal intubation in rabbits. New Zealand white rabbits were divided into 3 groups of 5 animals. In the first 2 groups, mainstream (nondiverting) or sidestream (diverting) capnography (MC and SC groups, re- spectively) was used; in the third group (LS group), a laryngoscope with a size 00 Miller blade was used to guide endotracheal tube placement. Anesthesia was induced through intramuscular administration of ketamine (10 mg/kg), medetomidine (0.1 mg/kg), and midazolam (1 mg/kg) mixed in the same syringe prior to administration. Intubation time was defined from the point of opening the jaws to the completion of the first capnogram after intubation. Intubation was accomplished successfully in all animals in both capnography groups, but 2 rabbits in the laryngoscopy group could not be intubated. Intubation time was compared among groups was compared by using one-way ANOVA, and posthoc Bonferroni testing was applied to isolate significant differences between groups. The intubation time (mean ± 1 SD) was 46.4 ± 12.6 s in the MC group, 147.2 ± 44.2 s in the SC group, and 385.0 ± 114.1 in the LS group, with intubation time significantly differing among all groups. In conclusion, both mainstream and sidestream capnography-guided endotracheal intubation techniques were more effective and efficient than conventional laryngoscope-guided endotracheal intubation in rabbits. Furthermore, mainstream capnography was preferred over sidestream capnography because mainstream capnography resulted in significantly shorter intubation times.

Simulation-based Randomized Paired Cross-over Comparison of Direct versus Video-assisted Laryngoscopy for Endotracheal Intubation by Inexperienced Operators

PurposeDirect laryngoscopy (DL) is the standard technique for endotracheal intubation. Video-assisted laryngoscopy (VL) has emerged as an alternative, particularly for difficult airway management. Nevertheless, DL and VL have not been systematically compared for simulation-based endotracheal intubation by inexperienced operators. MethodA prospective, randomized cross-over study was carried out at Lund University Faculty of Medicine, Malmö, Sweden, in 50 medical undergraduate students with no previous experience of endotracheal intubation in manikins or patients. Identical manikins (Rescue AnneTM, Laerdal AS, Stavanger, Norway) were consecutively intubated using DL with the Macintosh-type blade, and VL with the hyper-curved GlidescopeTM blade. Similarly designed and extensive instructional films on DL and VL techniques were shown to each study participant immediately before each training session, comprising ten consecutive individual intubation attempts with that specific device. No further instructions or feedback were provided by the study investigators. ResultsThe VL technique was found to be overall faster than DL, and also associated with fewer intubation failures (P = 0.0209), dental manipulations (P < 0.001), and oesophageal intubations (P < 0.0001). DiscussionSince VL for endotracheal intubation by inexperienced operators was more successful and associated with fewer adverse events than was DL, we propose that VL might be preferable to DL for endotracheal intubation by less experienced users. Further research is however strongly encouraged to validate these findings.

Difficult airway management in children and young adults with arthrogryposis.

ObjectiveTo review current evidence and experience with anesthesia and airway management issues in children and young adults with arthrogryposis.Data sourcesReview of existing world literature and description of personal experience at a center for children's orthopedic surgery and rehabilitation over 2 decades.MethodsDescription of common problems and their solutions in this unusual and diverse group of patients.ResultsArthrogryposis multiplex congenital includes more than 400 conditions that lead to congenital joint contractures affecting more than one body area. Among the many causes of arthrogryposis, 50%–65% fall into two large categories – amyoplasia and distal arthrogryposis. There is general agreement that best function in children with arthrogryposis is achieved through early mobilization of joint contractures. Children with arthrogryposis average >5 operative procedures during childhood. Anesthesia for these procedures may be complicated by limited jaw mobility and mouth opening, restricted lung development, positioning difficulties, difficult venous access and concerns about increased risk for malignant hyperthermia. 75% of arthrogryposis patients do not have a difficult airway. For those with a history of airway problems or those meeting criteria for a difficult airway, careful advanced planning helps to assure safe and successful surgery. We describe several specialized techniques for endotracheal intubation of children with arthrogryposis.ConclusionsChildren and young adults with arthrogryposis are a diverse group. Many pose unique challenges for airway and surgical management. Review of individual anesthesia records and careful advanced planning by a coordinated, experienced airway team can lead to best outcomes from arthrogryposis surgery.

Application of visual laryngoscope in the endotracheal intubation teaching of standardized resident training for different specialities

Visual endotracheal intubation technique was applied in the endotracheal intubation teaching for standardized resident training as a routine teaching appliance. The residents were divided into two groups, the anesthetic speciality group and the non-anesthetic speciality group. According to the different teaching targets, teaching periods and basic abilities, the differentiated teaching Settings were built and the different teaching schemes, evaluation index and teachers were applied for the two groups respectively for fulfilling the advantages of visual laryngoscope. Until now, more than a hundred residents were educated with the endotracheal intubation, and the teaching efficiency and quality were significantly improved, which also reduced the incidence of the complications related to endotracheal intubation. Key words: Visual laryngoscope; Endotracheal intubation; Anesthetic speciality; Non-anes-thetic speciality; Standardized resident training

Evaluation of the content, quality, reliability and accuracy of YouTube videos regarding endotracheal intubation techniques.

Today, the internet is widely used to obtain any type of information. The use of internet may facilitate healthcare professionals' education as well. We aimed to evaluate the content, accuracy, reliability and quality of YouTube videos regarding intubation, one of the most important skills for healthcare professionals. Of the 54,000 videos found using the keyword 'intubation', the first 50 were included in the study. The sources were divided into three categories: academicians, healthcare professionals and medical. The view ratio, like ratio, and video power index were used to determine the popularity while Journal of American Medical Association (JAMA) benchmark criteria were used for reliability. The extent of the information was evaluated based on the scoring system provided by us. The majority of the videos were uploaded by healthcare professionals (92%) including academicians. Twenty-seven (54%) videos had training purposes. The information point was highest in the academic group (4.6 ± 2.7); however, there was no significance between groups (P = 0.2). The mean JAMA score was highest in the academic group (1.9 ± 0.8), with a statistical significance (P = 0.00055). The JAMA score and information points were significantly higher in training videos compared to non-training videos (p=<0.001 and P = 0.003, respectively). Popularity ratios were similar between groups. Videos regarding medical skills should be accurate. Information on YouTube regarding intubation is limited and is of low quality. The establishment of an organization authorized to evaluate the content, quality, accuracy and reliability of the information on the internet regarding medical skills is warranted.

Degree of cervical mobility differs or not when using alternative way of intubation: Intubating laryngeal mask or classic laryngoscope

BackgroundSpine surgery needs a special consideration as regards minimizing the movement during intubation to avoid the hazards to spinal cord. The present study aims to highlight the preferable technique for cervical intubation. The Intubating Laryngeal Mask Airway (ILMA, Fastrach™ laryngeal mask company, Henle-on-Thomes, U.K.) is a supraglottic device specially designed to be an effective ventilator device and blind intubation guide in patient with normal and abnormal airways.Methods40 patients were involved and randomly assigned to two equal groups according to the used technique of endotracheal intubation: (Group 1): Intubating Laryngeal Mask technique and (Group 2): Direct laryngoscopy technique. Anesthesia was induced using a combination of 1 μg/kg fentanyl, 5 mg/kg thiopental sodium (sleeping dose) and atracurium 0.5 mg/kg (Intubating laryngeal Mask or the Macintosh blade) was used to secure the airway according to the patient group. Meanwhile a continuous videofluoroscopy was recorded. The radiographs were analyzed for movements in the cervical segments C1/2 and C2/3. A reference line was drawn following the dorsal alignment of C2. Another two lines, one connecting the anterior and posterior arch of C1, and one through the basal plate of C3, were drawn to transect the above mentioned reference line.ResultsThe mean cervical spine extension at C1/C2 was 77.2 ± 3.5 before intubation, 74.8 ± 4.3 during intubation, and 75.9 ± 4.2 after intubation for group 1, while it was 74.95 ± 4 before, 65.9 ± 4.4 during, and 68.75 ± 3.9 after intubation for group 2 there was statistically significant difference between LMA group (group 1) and direct laryngoscopy group (group 2) in the motion of cervical spine extension at C1/C2 during and after intubation where the p-value was <0.05.ConclusionThe ILM (Fastrach) is a satisfactory alternative to the currently used methods of airway management in cervical spine injuries and reduces movement of the cervical spine.

Rocuronium versus succinylcholine for rapid sequence induction intubation.

Patients often require a rapid sequence induction (RSI) endotracheal intubation technique during emergencies or electively to protect against aspiration, increased intracranial pressure, or to facilitate intubation. Traditionally succinylcholine has been the most commonly used muscle relaxant for this purpose because of its fast onset and short duration; unfortunately, it can have serious side effects. Rocuronium has been suggested as an alternative to succinylcholine for intubation. This is an update of our Cochrane review published first in 2003 and then updated in 2008 and now in 2015. To determine whether rocuronium creates intubating conditions comparable to those of succinylcholine during RSI intubation. In our initial review we searched all databases until March 2000, followed by an update to June 2007. This latest update included searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 2), MEDLINE (1966 to February Week 2 2015), and EMBASE (1988 to February 14 2015 ) for randomized controlled trials (RCTs) or controlled clinical trials (CCTs) relating to the use of rocuronium and succinylcholine. We included foreign language journals and handsearched the references of identified studies for additional citations. We included any RCT or CCT that reported intubating conditions in comparing the use of rocuronium and succinylcholine for RSI or modified RSI in any age group or clinical setting. The dose of rocuronium was at least 0.6 mg/kg and succinylcholine was at least 1 mg/kg. Two authors (EN and DT) independently extracted data and assessed methodological quality for the 'Risk of bias' tables. We combined the outcomes in Review Manager 5 using a risk ratio (RR) with a random-effects model. The previous update (2008) had identified 53 potential studies and included 37 combined for meta-analysis. In this latest update we identified a further 13 studies and included 11, summarizing the results of 50 trials including 4151 participants. Overall, succinylcholine was superior to rocuronium for achieving excellent intubating conditions: RR 0.86 (95% confidence interval (CI) 0.81 to 0.92; n = 4151) and clinically acceptable intubation conditions (RR 0.97, 95% CI 0.95 to 0.99; n = 3992, 48 trials). A high incidence of detection bias amongst the trials coupled with significant heterogeneity provides moderate-quality evidence for these conclusions, which are unchanged from the previous update. Succinylcholine was more likely to produce excellent intubating conditions when using thiopental as the induction agent: RR 0.81 (95% CI: 0.73 to 0.88; n = 2302, 28 trials). In the previous update, we had concluded that propofol was the superior induction agent with succinylcholine. There were no reported incidences of severe adverse outcomes. We found no statistical difference in intubation conditions when succinylcholine was compared to 1.2 mg/kg rocuronium; however, succinylcholine was clinically superior as it has a shorter duration of action. Succinylcholine created superior intubation conditions to rocuronium in achieving excellent and clinically acceptable intubating conditions.

Fiberscope Assisted Videolaryngoscope Intubation in the Surgical Treatment of TMJ Ankylosis.

Temporomandibular ankylosis is characterized by the formation of a bony mass which replaces normal temporomandibular joint (TMJ) articulation. Anaesthetic management in these patients requires expertise and dependable intubation technique that allows successful intubation due to anticipated difficulty in accessing the airway. A novel technique of endotracheal intubation is used for the successful airway management during the surgical treatment in patients with TMJ ankylosis with the assistance of fiberscope and GlideScope(®) videolaryngoscope. GlideScope(®) videolaryngoscope is a recently introduced system for tracheal intubation that has a dedicated video camera encased into a laryngoscope blade and provides better panoramic view than the conventional laryngoscopes. This technique avoids complications such as trauma to soft tissue structures surrounding the glottis during the passage of the tube over the fiberscope. It gives a clear view of the tube and its cuff position during intubation. It also abbreviates the time required for intubation which is a crucial determinant in this subset of patients owing to the difficult airway associated with paediatric age group.