Technique For Tracheal Intubation Research Articles

Universal paediatric videolaryngoscopy and glottic view grading: a prospective observational study.

Although videolaryngoscopy has been proposed as a default technique for tracheal intubation in children, published evidence on universal videolaryngoscopy implementation programmes is scarce. We aimed to determine if universal, first-choice videolaryngoscopy reduces the incidence of restricted glottic views and to determine the diagnostic performance of the Cormack and Lehane classification to discriminate between easy and difficult videolaryngoscopic tracheal intubations in children. We conducted a prospective observational study within a structured universal videolaryngoscopy implementation programme. We used C-MAC™ (Karl Storz, Tuttlingen, Germany) videolaryngoscopes in all anaesthetised children undergoing elective tracheal intubation for surgical procedures. The direct and videolaryngoscopic glottic views were classified using a six-stage grading system. There were 904 tracheal intubations in 809 children over a 16-month period. First attempt and overall success occurred in 607 (67%) and 903 (> 99%) tracheal intubations, respectively. Difficult videolaryngoscopic tracheal intubation occurred in 47 (5%) and airway-related adverse events in 42 (5%) tracheal intubations. Direct glottic view during laryngoscopy was restricted in 117 (13%) and the videolaryngoscopic view in 32 (4%) tracheal intubations (p < 0.001). Videolaryngoscopy improved the glottic view in 57/69 (83%) tracheal intubations where the vocal cords were only just visible, and in 44/48 (92%) where the vocal cords were not visible by direct view. The Cormack and Lehane classification discriminated poorly between easy and difficult videolaryngoscopic tracheal intubations with a mean area under the receiver operating characteristic curve of 0.68 (95%CI 0.59-0.78) for the videolaryngoscopic view compared with 0.80 (95%CI 0.73-0.87) for the direct glottic view during laryngoscopy (p = 0.005). Universal, first-choice videolaryngoscopy reduced substantiallythe incidence of restricted glottic views. The Cormack and Lehane classification was not a useful tool for grading videolaryngoscopic tracheal intubation in children.

A Prospective Comparative Study of Laryngeal Glottic View Using the Vie Scope® versus Standard Macintosh Laryngoscope in Morbidly Obese Patients.

The visualization of the glottis may be inadequate in morbidly obese patients when a standard Macintosh blade laryngoscope (MCL) is used. The Vie Scope® (VS) is a novel type laryngoscope consisting of a straight, enclosed, illuminated tube that offers intubation via a bougie using the paraglossal technique. In this prospective, nonrandomized comparative study, we tested the research hypothesis that the VS may improve visualization of the glottic larynx in comparison to the MCL. After obtaining institutional ethics committee approval, 60 morbidly obese patients (BMI >40 kg/m2) undergoing elective non-head and neck surgery were included in the study. After induction of general anesthesia (GA), the glottic visualization was performed using the two laryngoscopes in succession, first MCL size 3 or 4 followed by the VS and was assessed using the modified Cormack-Lehane scale. Tracheal intubation was performed using the VS The first pass intubation success and the total success rate was recorded only for the VS Intubation time was not measured because of the paired study design. Mean demographic data included: age 41.9±8.2 years, height 171.2±10.2 cm, weight 129.9±21.6 kg, BMI 44.95±3.85 kg/m2. Using MCL, Cormack-Lehane grade 1 was observed in 36 (60%) cases; grade 2 in 7/60 (11.6%); grade 3 in 13/60 (21.7%); and grade 4 in 4/60 (6.7%). Poor laryngeal views represented by grades 3 and 4 were observed in 28.4% of patients with the MCL. Grades obtained with the VS were all grade 1 (100%). The first attempt intubation success was in 58/60 (96.7%) with the VS. No complications were observed. The Vie Scope® laryngoscope, using the paraglossal technique of tracheal intubation, significantly improves visualization of the vocal cords in morbidly obese patients compared to the standard Macintosh laryngoscope.

A Comparative Study of Video Laryngoscopy to Direct Laryngoscopy for Endotracheal Intubation in Pediatric Patients.

Direct laryngoscopy is the standard method for intubation in pediatric patients. The introduction of video laryngoscopy brought a paradigm shift in managing pediatric airways. We compared the tracheal intubation technique between direct and video laryngoscopy with McIntosh Blade 2 in pediatric patients 2 - 8 years of age requiring airway management. The glottic view and the first pass success rate were compared and analyzed. An observational cross-sectional study was conducted with 120 children between 2 - 8 years with normal airways. They were divided into video laryngoscopy (Group V) and direct laryngoscopy (Group D). The primary outcome measures included time taken for intubation, number of attempts required, Cormack-Lehane glottic view, use of optimization maneuvers, the requirement of tube repositioning, and hemodynamic parameters before and after intubation. The time taken for intubation was longer in the video laryngoscopy group (group D, 24.28 sec vs. group V, 27.65 seconds (P = 0.01). The Cormack-Lehane glottic view was grade 1 in all the patients in the video laryngoscopy group, while only 35 children showed grade 1 in the direct laryngoscopy group. (P < 0.001). We observed a significant increase in both heart rate and mean arterial pressure in the video laryngoscopy group at 1, 3, 5, and 10 min after intubation (P < 0.001, P < 0.05). The time taken for intubation was more in group V, but the glottic view was much better, and the requirement for external maneuvers was also less. Pressure response to intubation was more in group V compared to group D.

Airway nerve blocks for awake tracheal intubation: A meta-analysis of randomized control trials and trial sequential analysis

Study objectiveThis systematic review and meta-analysis aimed to assess the superiority of airway nerve blocks versus airway anesthesia without nerve blocks for awake tracheal intubation (ATI). DesignSystematic review and meta-analysis of randomized controlled trials (RCTs). SettingAll studies that assessed the superiority of airway anesthesia technique for awake tracheal intubation were searched in PubMed, Web of Science, Cochrane Library, Ovid Medline, Embase and Chinese databases (including China National Knowledge Infrastructure, Wanfang database, and VIP databases) and trial registry databases from their inception to December 2022. PatientsAdult patients included in randomized controlled trials comparing airway anesthesia with or without airway nerve blocks for ATI. InterventionsAirway nerve (including superior laryngeal nerve, glossopharyngeal nerve, or recurrent laryngeal nerve) blocks for ATI. MeasurementsThe primary outcome was the intubation time. Secondary outcomes were quality of intubating conditions (including patient reaction to placement of the flexible scope and tracheal tube, coughing and gagging, and patient satisfaction) and overall complications during ATI. Main resultsFourteen articles with 658 patients were identified for analysis. When compared with airway anesthesia without nerve blocks, airway nerve blocks significantly reduced intubation time (standardized mean difference [SMD] -2.57, 95% CI -3.59- -1.56, p < 0.00001), improved anesthesia quality of ATI with higher no reaction to placement of the flexible scope and tracheal tube (relative risk [RR] 9.87; 95% CI 4.10–23.75, p < 0.00001), lower cough or gag reflex during intubation (RR 0.35, 95% CI 0.27–0.46, p < 0.00001), higher excellent patient satisfaction rate (RR 1.88, 95% CI 1.05–3.34, p = 0.03), and lower overall complications (RR 0.29, 95% CI 0.19–0.45, p < 0.00001). The overall quality of evidence was moderate. ConclusionsBased on current published evidence, airway nerve blocks provide better airway anesthesia quality for ATI with a shorter intubation time, better intubation conditions including higher no reaction to placement of the flexible scope and tracheal tube, lower cough or gag reflex during intubation, higher excellent patient satisfaction, and lower overall complications.

An Approach to Improve the Effectiveness of the Video-Assisted Intubating Stylet Technique for Tracheal Intubation: A Case Series Report

Direct laryngoscopy and videolaryngoscopy are currently the dominant tools for endotracheal intubation. However, the video-assisted intubating stylet, a type of videolaryngoscopy, has been shown to offer some advantages over these tools, such as rapid intubation time, high first-attempt success rates, less airway stimulation, and high subjective satisfaction. On the other hand, this optical intubating technique also has some technical limitations that need to be addressed, including camera lens fogging, airway path disorientation, and obscured visibility due to secretions. In this clinical report, we describe an approach that improves the visibility of the glottis by introducing a suctioning catheter into the nasopharyngeal airway to enhance the efficiency and accuracy of using the intubating stylet technique for tracheal intubation.

Achieving Successful Extubation and Cost-Effective Recovery Following Anesthetic Airway Management in Supracarinal Tracheal Reconstruction Surgeries: A Retrospective Analysis.

Introduction From an anesthesiologist's perspective, perioperative concerns related to supracarinal tracheal reconstruction surgery include having uninterrupted smooth ventilation without any laryngeal edema, glottic dysfunction, and airway leak. Surgical concerns comprise various kinds of anastomotic dissections, fistulas to innominate arteries, and the esophagus. The most serious complication following tracheal surgery is anastomotic separation, which might manifest modestly as stridor, respiratory distress, and extremis. To avoid dire repercussions, prompt management and securing the airway are necessary.Against this background,we wanted tohighlight the importance of early extubation and discharge of supracarinal tracheal reconstruction patients from hospitals without any postoperative complications and with the least expenses possible, since mostof these patients have already undergone postintubation tracheal stenosis and prolonged intensive care unit stay, and have experienced significant financialburden incurring from preceding events. Methodology Medical records of allpatients admitted for tracheal reconstruction during the period from March 2019 toApril 2022(four years)were reviewed to collect patient demographic details, surgical descriptions, anesthesia data, records of pre-anesthetic evaluations, and postoperative details up until the hospital discharge. Results The most common reason for tracheal stenosis among our patients was post-intubation tracheal stenosis (PITS), which was seen in 8/13 patients (61.53%);4/13patients (30.76%)had stridorat rest and underwent emergency tracheostomy preoperatively immediately following admission to the hospital.The stenosis was situated at a median distance of 3 cm [interquartilerange (IQR): 0.5-7] from the true vocal cords or 7 cm (IQR: 3-9) from the carina. The median length of tracheal resection was 2 cm(IQR: 1-4).Weobserved that the mode ofinductionfor airway management was tracheostomytubein four patients (with 90% tracheal stenosis), placement of laryngeal mask airway (LMA) with spontaneous ventilationin four patients (with 75% tracheal stenosis), andsmall-size (#5-7.5sizes) endotracheal tube (ETT) placement in five patients (with less than 75% tracheal stenosis).The postoperative complicationnoted was bleeding from the operative site in 1/13 patients (7.6%); a 0% mortality rate was noted during the hospital stay and up until six months post-discharge. We noted that the median duration of postoperative hospitalizationwas five days (IQR: 2-15), and the total cost incurred by each patientwas less thanINR 85,000 (USD 1,000). Conclusion Our analysis revealed that all our patients were extubated in the operative room andshifted to the ward. In the "open airway phase",standard distal tracheal intubation and cross-field ventilation techniques, and tracheal suturing were facilitated by the apnoea-ventilation-apnoea technique. Both the techniques along with the emergency tracheostomies done in severe tracheal obstruction preoperatively and intraoperative anesthesia management with the insertion of LMA Supreme,maintained with spontaneous breathing techniques, offered potential advantages in the management ofsupracarinal tracheal reconstruction surgeries. The multidisciplinary teamwork along with close communication and good rapport with the surgical team was found to be the key factor in the fast-track extubation and recovery of these patients.

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

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

Videolaryngoscopy as a first-intention technique for tracheal intubation in unselected surgical patients: a before and after observational study

BackgroundUsing a Macintosh-style videolaryngoscope as a first-intention device for tracheal intubation of unselected patients in the operating room has not often been studied. We hypothesised that using a Macintosh-style videolaryngoscope as a first-intention device is associated with an increased proportion of easy tracheal intubation. MethodsIn a quality improvement project for airway management aimed at implementing a Macintosh-style videolaryngoscope as a first-intention device, we included all consecutive tracheal intubations in adults from March, 2017 to September, 2020 in two French teaching hospitals. We divided the cohort into three temporal cohorts: the pre-intervention, implementation, and post-intervention periods. The primary outcome was the proportion of easy airway management. The secondary outcomes were the rescue technique, Cormack–Lehane III or IV view, and operator-reported difficulty of intubation. Data from one hospital compliant with the quality improvement project were compared with data from a non-compliant hospital. ResultsA total of 26 692 tracheal intubations were performed. Among 11 938 intubations included in the compliant hospital, 5487 were included in the pre-intervention, 1845 in the implementation, and 4606 in the post-intervention periods. In comparison to the pre-intervention period, the proportions of easy tracheal intubation increased from 94.3% (5177 of 5487) to 98.7% (4547 of 4606)) in the post-intervention period (+4.4% [95% confidence interval 3.7–5.1%], P<0.001). In comparison to the pre-intervention period, all secondary outcome proportions were significantly lower in the post-intervention period. No significant changes were noted in the non-compliant hospital between the pre- and post-intervention periods. ConclusionsUsing a Macintosh-style videolaryngoscope as a first-intention device for tracheal intubation in the operating room was associated with a significant increase in the proportion of easy tracheal intubation, compared with use of the standard Macintosh laryngoscope.

Video-Assisted Stylet Intubation with a Plastic Sheet Barrier, a Safe and Simple Technique for Tracheal Intubation of COVID-19 Patients.

As the COVID-19 pandemic evolves, infection with the Omicron variants has become a serious risk to global public health. Anesthesia providers are often called upon for endotracheal intubations for COVID patients. Expedite and safe intubation can save patient’s life, while minimizing the virus exposure to the anesthesia provider and personnel involved during airway intervention is very important to protect healthcare workers and conserve the medical work force. In this paper, we share clinical experience of using a video-assisted intubating stylet technique combined with a simple plastic sheet barrier placed over the patients’ mouth for tracheal intubation during the Omicron crisis in Taiwan. We demonstrated that the use of an intubating stylet combined with plastic sheet barrier is swift, safe, and accurate in securing the airway in patients with COVID-19.

EVALUATION OF SKILL ACQUISITION OF VIDEOLARYNGOSCOPY IN COMPARISON TO DIRECT LARYNGOSCOPY IN POSTGRADUATE MEDICAL STUDENTS: A MANIKIN STUDY

Background: Direct laryngoscopy with Macintosh laryngoscope (ML) is the gold standard technique for tracheal intubation. However, visualization of the larynx and subsequent tracheal intubation may not be possible in difcult airways. TruView video laryngoscope (TVL) can provide good visualization of the glottis and visual conrmation of tracheal intubation in a difcult airway scenario. This manikin study was carried out to compare the skill acquisition for videolaryngoscopy using TVL and compare it with direct laryngoscopy using ML, in easy and difcult airway scenarios, in TVL novice participants. Material and methods: Thirty resident doctors were randomized to participate in a crossover, manikin study. Participants were asked to intubate a manikin in easy and difcult airway scenarios using TruView and Macintosh laryngoscope. Two trials were conducted at one-week interval and at the end of each trial parameters of Intubation time, Cormack-Lehane (CL) grading, success of intubation and ease of intubation which reect skill acquisition were recorded. All 30 participants completed the study. Results: In the easy scenario most results were comparable between the two devices. The TVL scored over ML in all aspects of difcult intubation with signicantly lesser time for intubation (23.27 ± 1.8sec, P&lt;0.0001), lower CL grade (1&amp;2-100%), higher success of intubation in the rst attempt (83.33%, P=0.0016) and greater ease of intubation (100%, P&lt;0.0001). Conclusion: TVL scores over ML in difcult airway scenarios in novice users of TVL, within a short learning time.

Videographic Assessment of Tracheal Intubation Technique in a Network of Pediatric Emergency Departments: A Report by the Videography in Pediatric Resuscitation (VIPER) Collaborative

We sought to describe the tracheal intubation technique across a network of children's hospitals and explore the association between intubation technical adjuncts and first-attempt success as well as between laryngoscopy duration and the incidence of hypoxemia. We conducted a prospective observational study in 4 tertiary pediatric emergency departments of the Videography in Pediatric Resuscitation Collaborative. Children undergoing tracheal intubation captured on video were eligible for inclusion. Data on intubator background, patient characteristics, technical characteristics (eg, use of videolaryngoscopy and apneic oxygenation), and procedural outcomes were obtained through a video review. We obtained complete data on first attempts in 494 patients. The first-attempt success rate was 67%, the median laryngoscopy duration was 35 seconds (interquartile range 25 to 40), and hypoxemia occurred in 15% of the patients. Videolaryngoscopy was used for at least a part of the procedure in 48% of the attempts, and it had no association with success or the incidence of hypoxemia. Attempts in which videolaryngoscopy was used for the entire procedure (compared with direct laryngoscopy for the entire procedure) had a longer duration (the difference between the medians was 6 seconds; 95% confidence interval, 1 to 12 seconds). Intubation attempts longer than 45 seconds had a greater incidence of hypoxemia (29% versus 6%). Furthermore, apneic oxygenation was used in 8% of the first attempts. Among children undergoing tracheal intubation in a group of pediatric emergency departments, first-attempt success occurred in 67% of the patients. Videolaryngoscopy use was associated with longer laryngoscopy durations but was not associated with success or the incidence of hypoxemia.

Comparison between Standard Technique versus Reverse Manoeuvre of Airtraq Insertion for Tracheal Intubation in Lean versus Obese Patients undergoing Surgery under General Anaesthesia: A Randomised Clinical Study

Introduction: Obese patients pose challenge to anaesthesiologist in terms of securing airway due to large tongue and anatomical variations, need a novel tracheal intubation technique to quickly secure airway in obese individuals. The airtraq laryngoscope with reverse technique of insertion is used to secure airway without classical sniffing position. Aim: To compare the two techniques of airtraq insertion, standard and reverse manoeuvre, in lean versus obese patients undergoing surgery under general anaesthesia. Materials and Methods: This randomised clinical study was conducted from July 2012 to January 2014 at Seth GS Medical College and KEM Hospital, Mumbai, Maharasthra, India in a total of 200 American Society of Anaesthesiologists (ASA) I-III undergoing surgery under general anaesthesia. Both lean and obese patients were randomly allocated to each technique. After induction of anaesthesia intubation was performed by an expert anaesthesiologist with each technique (three attempts) were used to intubate trachea. If there was a failure, switch over technique was applied. All the groups were analysed for intubation time, number of attempts, ease of intubation Visual Analogue Scale (VAS), haemodynamics, and complications. Results: Both lean and obese groups were comparable in the airway and demographic characteristics. In lean patients there was no significant difference between intubation time with both standard and reverse manoeuvre. While in obese patients reverse manoeuvre (11.84±1.99 seconds) significantly reduced exposure time by 13 seconds as compared to standard technique (24.02±6.94 seconds), thereby reducing total duration of intubation (26.08±1.16 seconds) as compared to total duration of intubation with standard technique (39.62±8.95 seconds). Lean group were comparable in number of attempts with standard technique (47 1st /3 2nd attempt) and reverse manoeuvre (49 1st /1 2nd attempt). Obese group with reverse manoeuvre all were intubated with first attempt (50 1st) with standard technique (46 1st /1 2nd attempt) and there was switch over from standard to reverse technique in three patients. Both lean and obese groups were comparable in complications with both technique. Conclusion: Reverse manoeuvre proved beneficial in obese patients as it reduced intubation time as compared to standard technique, while lean patients showed no difference.

Experience of using a neuromonitor during thyroid surgery in children

Background. Thyroid surgery is associated with the risk of complications that worsen the course of the postoperative period and lead to disability of patients. One of these complications is damage to the recurrent laryngeal nerve, causing impaired phonation, and in the case of bilateral lesions, respiratory impairment.&#x0D; The aim of this work was to study the features of the technique and the effectiveness of the use of neuromonitoring during operations on the thyroid gland.&#x0D; Materials and methods. The study was conducted on a series of 55 clinical observations of thyroid diseases in children. Intraoperative monitoring was performed using the Inomed C2 Nerve Monitor, which records the action potential on the vocal folds caused by electrical stimulation of the recurrent laryngeal nerve.&#x0D; Results. In 52 cases, no decrease in the amplitude of the neuromonitor signal was observed during surgical interventions. In two cases, intraoperatively, a decrease in the signal amplitude associated with excessive traction of the nerve was revealed. Another observation noted the absence of a signal at the end of the operation and the preservation of the mobility of the vocal cords in the postoperative period, probably due to technical errors in performing intraoperative monitoring. In one patient, during the operation, changes in the neuromonitor signal did not occur, but after surgery, a violation of the vocal function was noted, which fully recovered within 3 months. In all likelihood, these changes are due to the technique of tracheal intubation.&#x0D; Conclusions. Neuromonitoring is an additional method for finding the recurrent laryngeal nerve, but in no way replaces the need for delicate anatomical identification of the latter.

Practice and outcomes of airway management in patients with cervical orthoses

Increasing evidence indicates an association of video laryngoscopy with the success rate of airway management in patients with neck immobilization. Nevertheless, clinical practice protocols for tracheal intubation in patients immobilized using various types of cervical orthoses and the outcomes remain unclear. We retrospectively assessed the tracheal intubation techniques selected for patients immobilized using cervical orthoses from 2015 to 2018. The endpoints were the intubation outcomes of the different techniques and the factors associated with the selection of the technique. We included 218 patients, 118 of whom wore halo vest braces (halo vest group) and 100 wore cervical collars (collar group). GlideScope video laryngoscopy (GVL) and fiberoptic bronchoscopy (FOB) were the initial intubation methods in 98 and 120 patients, respectively. GVL had a higher first-attempt success rate than did FOB in the collar group (p=0.002) but not in the halo vest group (p=0.522). GVL was associated with a lower risk of episodes of SaO2< 90% (adjusted relative risk [aRR], 0.11; 95% CI, 0.02-0.67; p=0.016) and shorter intubation time (aRR, -3.52; 95% CI, -4.79∼-2.25; p<0.001) in the collar group. However, in the halo vest group, more frequent requirement of a rescue technique (p=0.002) and necessity of patient awakening (p=0.001) was noted when GVL was used. Use of the halo vest brace and noting of severe cord compression were independent predictors of the initial selection of FOB. Caution should be exercised when using GVL for tracheal intubation in patients immobilized using halo vest braces.

A systematic review of meta-analyses comparing direct laryngoscopy with videolaryngoscopy.

PurposeIn the preceding 20 years, many randomized-controlled trials and meta-analyses have compared direct Macintosh laryngoscopy with videolaryngoscopy. The videolaryngoscope blades have included both traditional Macintosh blades and hyperangulated blades. Macintosh and hyperangulated blades differ in their geometry and technique for tracheal intubation; certain patient populations may benefit from one blade type over another. The primary objective of this systematic review was to assess whether published meta-analyses comparing direct Macintosh laryngoscopy to videolaryngoscopy have accounted for the videolaryngoscope blade type. Secondary objectives evaluated heterogeneity among practitioner experience and specialty, clinical context, patient population, and original primary study outcomes.SourceA search was performed across Ovid Medline, Ovid Embase, ClinicalKey, PubMed, TRIP, AccessAnesthesiology, Google Scholar, and ANZCA discovery. A systematic review identified meta-analyses which compared direct Macintosh laryngoscopy to videolaryngoscopy. There were no patient age or clinical specialty restrictions. Exclusion criteria included non-English language, studies comparing non-Macintosh blade to videolaryngoscopy, and studies in awake patients.Principal findingsTwenty-one meta-analyses were identified that were published between 1 January 2000 and 7 May 2020. Macintosh and hyperangulated videolaryngoscope blades were combined in most studies (16/21; 76%). Heterogeneity was also present among practitioner experience (20/21; 95%), clinician specialty (15/21; 71%), and clinical locations (10/21; 48%). Adult and pediatric patients were combined or not defined in 5/21 studies (24%). The primary outcomes of the meta-analyses varied, with the most common (7/21; 33%) being first-pass tracheal intubation success.ConclusionsHeterogeneity across important clinical variables is common in meta-analyses comparing direct Macintosh laryngoscopy to videolaryngoscopy. To better inform patient care, future videolaryngoscopy research should differentiate blade type, clinical context, and patient-related primary outcomes.

Tracheal intubation in patients at risk for cervical spinal cord injury: A systematic review.

Tracheal intubation in patients at risk for secondary spinal cord injury is potentially difficult and risky. To compare tracheal intubation techniques in adult patients at risk for secondary cervical spinal cord injury undergoing surgery. Primary outcome was first-attempt failure rate. Secondary outcomes were time to successful intubation and procedure complications. Systematic review and meta-analysis of randomized controlled trials (RCTs) with trial sequential analysis (TSA). Databases searched up to July 2019. Randomized controlled trials comparing different intubation techniques. We included 18 trials enrolling 1972 patients. Four studies used the "awake" approach, but no study compared awake versus non-awake techniques. In remaining 14 RCTs, intubation was performed under general anesthesia. First-attempt failure rate was similar when comparing direct laryngoscopy or fiberoptic bronchoscopy versus other techniques. A better first-attempt failure rate was found with videolaryngoscopy and when pooling all the fiberoptic techniques together. All these results appeared not significant at TSA, suggesting inconclusive evidence. Intubating lighted stylet allowed faster intubation. Postoperative neurological complications were 0.34% (no significant difference among techniques). No life-threatening adverse event was reported; mild local complications were common (19.5%). The certainty of evidence was low to very low mainly due to high imprecision and indirectness. Videolaryngoscopy and fiberoptic-assisted techniques might be associated with higher first-attempt failure rate over controls. However, low to very low certainty of evidence does not allow firm conclusions on the best tracheal intubation in patients at risk for cervical spinal cord injury.

A Study on Tracheal Intubation Technique in Six Patients with Deep Neck Abscesses

A Study on Tracheal Intubation Technique in Six Patients with Deep Neck Abscesses

The retrograde tracheal intubation technique for difficult airway management: old but still working

Tracheal intubation performed with direct laryngoscopy remains a preferred choice for securing the airway. In maxillofacial surgery patients, difficult airway may require using alternative techniques. Retrograde tracheal intubation (RTI) technique is an effective and safe option for some of these cases. We report our experience with a modified RTI technique in a 72-year-old man (body mass index, 20.3) affected by a pleomorphic adenoma of the lower jaw extending to the oropharynx and rhinopharynx. Our RTI technique included a 17-G Fantoni modified tracheal needle, a 150 cm long Teflon guide wire (SG), and an 83 cm long Cook airway exchange catheter. Preserving spontaneous breathing with a combination of propofol and remifentanil infusion, we performed RTI using a 17-G Fantoni cricothyrotomy needle inserted between first and second tracheal ring. The patient remained breathing spontaneously for the duration of the procedure, and his vital signs were maintained within normal limits. This case report offers an opportunity to discuss our experience and use of retrograde tracheal intubation. The RTI can be an alternative to awake intubation, and maintaining proficiency and training is necessary to guarantee favorable outcomes.

Improvement of laryngoscopic view by hand-assisted elevation and caudad traction of the shoulder during tracheal intubation in pediatric patients

Pediatric patients have large heads and relatively small bodies, making it difficult to perform intubation even in the sniffing position. Therefore, this study was planned on the assumption that hand-assisted elevation and caudad traction of the shoulder (HA-ECTS) would compensate for the laryngoscopic view. In this observational study, 45 pediatric patients aged 0–36 months with an ASA physical status of I-III and scheduled for elective surgery under general anesthesia were enrolled. HA-ECTS was defined as hand-assisted personalized traction in the upper and caudad directions with both hands under the lower cervical area. The POGO (percentage of glottis opening) score, MO (mouth opening), and LHS (laryngoscopic handling score) were compared before and after HA-ECTS. The median [range] POGO score was 30[10–50]% and 60[15–80]% before and after HA-ECTS, respectively (median difference, 20; 95% confidence interval [CI] 10 to 25%; P = 0.002). MO was 1.0[0.8–1.9] cm and 1.8[1.3–2.0] cm before and after HA-ECTS, respectively (median difference, 0.45 cm; 95% CI 0.25 to 0.60; P < 0.001). The ease of laryngoscopic handling was improved after HA-ECTS(P < 0.001). The application of HA-ECTS to pediatric patients younger than 3 years improved POGO score, MO, and LHS and could prove to be an assistive technique for tracheal intubation.

Face-to-face intubation using a lightwand in a patient with severe thoracolumbar kyphosis: a case report

BackgroundSevere deformity of the thoracolumbar spine may cause difficulty in airway management during induction of anesthesia. Therefore, special attention must be devoted to patient safety.Case presentationA 65-year-old male with severe thoracolumbar kyphosis was scheduled to undergo posterior spinal fusion under general anesthesia. Due to his inability to lie supine, conventional tracheal intubation under direct laryngoscopy was difficult. Alternatively, face-to-face tracheal intubation using a lightwand in the semi-recumbent position was performed. Intubation was successful on the first attempt without any complications.ConclusionsThe face-to-face intubation technique using a lightwand is one of several alternative techniques for tracheal intubation in patients who cannot lie supine.