Use Of Direct Laryngoscopy Research Articles

Video versus Direct Laryngoscopy for Urgent Intubation of Newborn Infants

BackgroundRepeated attempts at endotracheal intubation are associated with increased adverse events in neonates. When clinicians view the airway directly with a laryngoscope, fewer than half of first attempts are successful. The use of a video laryngoscope, which has a camera at the tip of the blade that displays a view of the airway on a screen, has been associated with a greater percentage of successful intubations on the first attempt than the use of direct laryngoscopy in adults and children. The effect of video laryngoscopy among neonates is uncertain.MethodsIn this single-center trial, we randomly assigned neonates of any gestational age who were undergoing intubation in the delivery room or neonatal intensive care unit (NICU) to the video-laryngoscopy group or the direct-laryngoscopy group. Randomization was stratified according to gestational age (<32 weeks or ≥32 weeks). The primary outcome was successful intubation on the first attempt, as determined by exhaled carbon dioxide detection.ResultsData were analyzed for 214 of the 226 neonates who were enrolled in the trial, 63 (29%) of whom were intubated in the delivery room and 151 (71%) in the NICU. Successful intubation on the first attempt occurred in 79 of the 107 patients (74%; 95% confidence interval [CI], 66 to 82) in the video-laryngoscopy group and in 48 of the 107 patients (45%; 95% CI, 35 to 54) in the direct-laryngoscopy group (P<0.001). The median number of attempts to achieve successful intubation was 1 (95% CI, 1 to 1) in the video-laryngoscopy group and 2 (95% CI, 1 to 2) in the direct-laryngoscopy group. The median lowest oxygen saturation during intubation was 74% (95% CI, 65 to 78) in the video-laryngoscopy group and 68% (95% CI, 62 to 74) in the direct-laryngoscopy group; the lowest heart rate was 153 beats per minute (95% CI, 148 to 158) and 148 (95% CI, 140 to 156), respectively.ConclusionsAmong neonates undergoing urgent endotracheal intubation, video laryngoscopy resulted in a greater number of successful intubations on the first attempt than direct laryngoscopy. (Funded by the National Maternity Hospital Foundation; VODE ClinicalTrials.gov number, NCT04994652.)

Factors associated with 30- and 90-day mortality in intubations among critically ill patients.

Emergency intubations are commonly associated with adverse events when performed in critically ill patients. A detailed look at intubation factors and their association with procedural success and mortality has yet to be fully conducted. A total of 299 successive intubations at a tertiary Veteran Affair hospital were analyzed. Situational factors, personnel involved, intubation indications, induction agents, and airway management techniques were prospectively collected and entered into univariable and multivariable analyses to identify factors associated with procedural difficulty and mortality. The use of paralytics was associated with easier intubations (OR: 0.31, 95% CI: 0.11-0.87, p = .03). The use of direct laryngoscopy or video laryngoscopy had no significant association with difficult intubation. Factors associated with increased 30-day mortality were cardiac arrest (OR: 7.90, 95% CI: 2.77-22.50, p < .001), hypoxia as indication for intubation (OR: 2.31, 95% CI: 1.23-4.35, p = .009), and nadir SpO2 < 90% (OR: 2.70, 95% CI: 1.01-7.21, p = .048). Presence of an attending anesthesiologist during intubation was associated with a lower 30-day mortality (OR: 0.11, 95% CI: 0.04-0.29, p < .001). Factors associated with increased 90-day mortality were cardiac arrest (OR: 6.57, 95% CI: 2.23-19.34, p = .001), hypoxia as indication for intubation (OR: 1.97, 95% CI: 1.10-3.55, p = .023), and older age (OR: 1.38, 95% CI: 1.07-1.78, p = .013). Similarly, presence of an attending anesthesiologist was found to be associated with a lower 90-day mortality (OR: 0.19, 95% CI: 0.07-0.50, p = .001). Cardiovascular and respiratory instability were associated with increased 30- and 90-day mortality. Presence of an attending anesthesiologist was associated with a better survival following intubation outside operating room.

Improving Safety in Chondrolaryngoplasty.

Improving Safety in Chondrolaryngoplasty.

A Systematic Review of Meta-Analyses Comparing Direct Laryngoscopy With Videolaryngoscopy

(Can J Anaesth. 2021;68:706–714. doi: 10.1007/s12630-021-01921-7. Epub January 29, 2021) As videolaryngoscopy (VL) becomes a preferred technique for airway management, it is important to assess literature comparing the benefits of VL and the traditional use of direct laryngoscopy via a Macintosh blade (Mac-DL). VLs use both Macintosh and hyperangulated blades, though it is unclear whether previous studies have differentiated between blade types. The aim of this study was to review published meta-analyses of VL.

Prehospital Pediatric Respiratory Distress and Airway Management Interventions: An NAEMSP Position Statement and Resource Document

Devices and techniques such as bag-valve-mask ventilation, endotracheal intubation, supraglottic airway devices, and noninvasive ventilation offer important tools for airway management in critically ill EMS patients. Over the past decade the tools, technology, and strategies used to assess and manage pediatric respiratory and airway emergencies have evolved, and evidence regarding their use continues to grow. NAEMSP recommends: Methods and tools used to properly size pediatric equipment for ages ranging from newborns to adolescents should be available to all EMS clinicians. All pediatric equipment should be routinely checked and clearly identifiable in EMS equipment supply bags and vehicles. EMS agencies should train and equip their clinicians with age-appropriate pulse oximetry and capnography equipment to aid in the assessment and management of pediatric respiratory distress and airway emergencies. EMS agencies should emphasize noninvasive positive pressure ventilation and effective bag-valve-mask ventilation strategies in children. Supraglottic airways can be used as primary or secondary airway management interventions for pediatric respiratory failure and cardiac arrest in the EMS setting. Pediatric endotracheal intubation has unclear benefit in the EMS setting. Advanced approaches to pediatric ETI including drug-assisted airway management, apneic oxygenation, and use of direct and video laryngoscopy require further research to more clearly define their risks and benefits prior to widespread implementation. If considering the use of pediatric endotracheal intubation, the EMS medical director must ensure the program provides pediatric-specific initial training and ongoing competency and quality management activities to ensure that EMS clinicians attain and maintain mastery of the intervention. Paramedic use of direct laryngoscopy paired with Magill forceps to facilitate foreign body removal in the pediatric patient should be maintained even when pediatric endotracheal intubation is not approved as a local clinical intervention.

Adoption of video laryngoscopy by a major academic anesthesia department.

Aim: To describe the adoption patterns of intubating devices used at a major teaching and research facility. Materials& methods: Retrospective analysis of 2012-2019 data on frequency and trends in airway management devices collected from our anesthesia information management system. Results: Use of direct laryngoscopy was more frequent, but there was a downward trend in use over time (p<0.008) in favor of video laryngoscopy (VL), which increased significantly (p<0.008). The largest growth among devices was the McGrath VL, which increased from 0.2% in 2012 to 36.2% of cases in 2019. Conclusion: Our study shows a clear increase in VL usage which has implications in quality of care and medical education.

Video laryngoscopy for endotracheal intubation of adult patients with suspected/ confirmed COVID-19. A systematic review and meta-analysis of randomized controlled trials

Study objective: During a pandemic, medical personnel while in contact with patients with suspected/confirmed COVID-19 should wear full personal protective equipment (PPE) for aerosol-generating procedures to reduce the risk of infection. Most studies of intubation in level C PPE conditions have been relatively small. Our aim is to quantify the available data on success rates in order to provide an evidence-based benchmark to gauge performance in the published literature. Methods: A structured literature search was performed with PubMed, Scopus, Embase, Web of Science, and Cochrane databases. The electronic database search was supplemented by searching Google Scholar and by back-searching the reference lists of identified studies for suitable articles. Data were evaluated and extracted by two independent reviewers on the basis of qualitative and quantitative variables of interest. Q statistic and I2 statistics were used to assess the heterogeneity between the studies. Results : Fifteen randomized controlled trials were included. The use of PPE during intubation as compared with intubation without PPE reduced intubation efficacy (90.0% vs. 97.9%; RR = 0.94; 95%CI: 0.90–0.99; p &lt; 0.001) and increased the procedure time (MD = 7.73; 95%CI: 4.98–10.47; p &lt; 0.001). Direct laryngoscopy compared with video laryngoscopes offered similar intubation success rate (93.6% vs. 92.3%; RR = 0.99; 95%CI: 0.97–1.02; p = 0.66) and shorter intubation time (MD = 63; 95%CI: -0.77–12.03; p = 0.08). However, subgroup analysis showed that intubation with Macintosh blade video laryngoscopes was more effective than that with direct laryngoscopes (98.1% vs. 96.4%; RR = 1.00; 95%CI: 0.97–1.03; p = 0.90). Conclusions: Our meta-analysis suggests that PPE reduces the effectiveness of endotracheal intubation. The use of direct laryngoscopy for intubating patients with suspected/confirmed COVID-19 by an intubator wearing level C PPE is associated with overall intubation time reduction and an increase in intubation success rate compared with video laryngoscopes. However, the findings suggest that Macintosh blade video laryngoscopes during endotracheal intubation with PPE may be an alternative to direct laryngoscopes. Video laryngoscopy can be helpful for less experienced personnel.

Does video laryngoscopy or direct laryngoscopy affect first-pass success rates for intubation among attending and non-attending emergency physicians in the emergency department?

Background: To our knowledge, there has been no study comparing intubation characteristics between attending and non-attending emergency physicians in Southeast Asia. We aim to identify whether the use of direct laryngoscopy compared to video laryngoscopy affects first-pass success rates between attending emergency physicians and non-attending emergency physicians. Materials and methods: Retrospective analysis of data from 2009 to 2016 in an existing airway registry managed by an academic Emergency Department in Singapore. Primary outcome was first-pass success intubation rate. Secondary outcome was first-pass success rate for difficult intubations. Difficult intubations were defined as LEMON (Look externally, Evaluate 3-3-2 rule, Mallampati score, Obstruction, Neck mobility) score of more than 1. Results: There were a total of 2909 intubations. Attending emergency physicians conducted 1748 intubations, while non-attending emergency physicians conducted 1161 intubations. The first-pass success rates for AEP were 84.2% and 67.4% for non-attending emergency physicians. Direct laryngoscopy was used in 86.2% of intubation by attending emergency physicians compared to 89.0% in the intubation by non-attending emergency physicians. Also, 7.6% of intubations by the attending emergency physicians were difficult compared to 8.8% by the non-attending emergency physicians (p = 0.25). Logistic regression of the effect of laryngoscopy device on first-pass success in all intubations showed a negative association with video laryngoscopy (odds ratio, 0.70; 95% confidence interval, 0.56–0.88). In the subgroup of difficult intubations, non-attending emergency physicians are 1.54 times (95% confidence interval, 0.53–4.42) as likely to have first-pass success with video laryngoscopy compared to that with direct laryngoscopy. On the contrary, in the subgroup of difficult intubations, attending emergency physicians are 0.90 times (95% confidence interval, 0.38–2.12) as likely to have first-pass success with video laryngoscopy compared to that with direct laryngoscopy. Conclusion: Our study showed that video laryngoscopy has a lower first-pass success rate for all intubations in general. Intubations performed by attending emergency physicians with direct laryngoscopy were associated with a higher first-pass success rate.

The use of direct laryngoscopy and ultrasound in the perioperative assessment of mobility of vocal folds in patients treated surgically due to goiter

Poland has about 25000–30000 thyroid glands operations per year. These kind of operations are in fourth place as to the frequency of scheduled operations. Most patients have total thyroidectomy. In addition to the classic method of accessing the collar cut at the neck, there are also alternative access, e.g. through the vestibule of the mouth or armpit. Surgery carries the risk of serious and even life-threatening consequences. One of the most serious complications of this surgery is failure of one or both laryngeal recurrents nerves. Laryngeal recurrents nerves are responsible for the proper functioning of vocal folds. Depending on the failure degree, results in disruption of phonation, difficulties in taking solid and liquid food, limitation of physical performance, impaired breathing to respiratory failure. The aim of this study is to assess the prevalence of early injury of the laryngeal nerves by evaluating the operation of vocal folds in direct laryngoscopy and ultrasonography. The study was carried out from 15/05/2018 to 17/01/2019 at the Department of General and Oncological Surgery. The patients were qualified for random examination from among the total number of patients qualified for goiter surgery in the Clinic. Direct laryngoscopy was performed in the Endoscopic Laboratory of the General and Oncological Surgery Clinic of the Medical University of Lodz. The ultrasound of the vocal folds was performed in the Department of Diagnostic Imaging. In the study period, 42 patients were qualified to participate in the study. In the study group, bilateral, early paresis of vocal folds was diagnosed in two patients (4.76%) and unilateral early paresis of vocal fold in seven patients (16.67%). Both operations, complicated by bilateral paresis of vocal folds, were performed without the use of intraoperative neuromonitoring (IONM - intraoperative neuromonitoring). One-sided paresis of vocal folds occurred in 3 patients (7.14%) operated without neuromonitoring, and 4 patients (9.52%) with intraoperative neuromonitoring. The study found that a severe complication in the form of early bilateral paresis of vocal folds occurred in operations without the use of neuromonitoring. A similar occurrence of one-sided damage to the vocal fold indicates a lack of connection with the additional support used in the form of intraoperative neuromonitoring.

The efficacy of GlideScope® videolaryngoscopy compared with direct laryngoscopy in children who are difficult to intubate: an analysis from the paediatric difficult intubation registry

BackgroundWe analysed data from the Paediatric Difficult Intubation Registry examining the use of direct laryngoscopy and GlideScope® videolaryngoscopy. MethodsData collected by a multicentre, paediatric difficult intubation registry from 1295 patients were analysed. Rates of success and complications between direct laryngoscopy and GlideScope videolaryngoscopy were analysed. ResultsInitial (464/877 = 53% vs 33/828 = 4%, Z-test = 22.2, P < 0.001) and eventual (720/877 = 82% vs. 174/828 = 21%, Z-test = 25.2, P < 0.001) success rates for GlideScope were significantly higher than direct laryngoscopy. Children weighing <10 kg had lower success rates with the GlideScope than the group as a whole. There were no differences in complication rates per attempt between direct laryngoscopy and GlideScope. The direct laryngoscopy group had more complications associated with the greater number of attempts needed to intubate. There were no increased risks of hypoxia or trauma with GlideScope use. Each additional attempt at intubation with either device resulted in a two-fold increase in complications (odds ratio: 2.0, 95% confidence interval: 1.5–2.5, P < 0.001). ConclusionsDuring difficult tracheal intubation in children, direct laryngoscopy is an overly used technique with a low chance of success. GlideScope use was associated with a higher chance of success with no increased risk of complications. GlideScope use in children with difficult tracheal intubation has a lower success rate than in adults with difficult tracheal intubation. Children weighing less than 10 kilograms had lower success rates with either device. Attempts should be minimized with either device to decrease complications.

Airway Management in an Infant with a Large Supraglottic Mass after Failed Fiberoptic Intubation

BackgroundFiberoptic bronchoscope−guided tracheal intubation is the gold standard for managing patients with supraglottic growths. In infants with a large and overhanging epiglottis, the success of fiberoptic-guided intubation relies heavily on the available space between the inferior surface of the epiglottis and the posterior pharyngeal wall or, more specifically, the superior surface of the supraglottic growth. Case ReportWe describe the inability to negotiate the tip of the fiberscope between the epiglottis and the supraglottic growth and the successful use of direct laryngoscopy to improve the available space along with the usefulness of “bubbling of air” to locate the glottic opening in an infant. Why Should an Emergency Physician Be Aware of This?We emphasize the role of the emergency physician in managing such patients. Most of the time, the setting is not ideal in such emergency situations and the most qualified clinician to treat them is the emergency physician. The knowledge and skills of the emergency physician, along with awareness of the possible techniques for airway management, can be lifesaving.

Trachway Intubating Stylet Facilitates the Double-Lumen Endobronchial Tube Placement in Patients with Limited Mouth Opening

Intubation for one lung ventilation in patients with difficult airways can be a challenge. Severely limited mouth opening restricts the use of direct laryngoscopy or video-assisted laryngoscopy. We present two patients with limited mouth opening undergoing video-assisted thoracoscopic decortication, who were successfully intubated with left-sided double-lumen endobronchial tube (DLT) using the Trachway® intubating stylet. This technique provides a safe and reliable method for DLT intubation in patients with limited mouth opening.

The “Other Tube” in the Airway

The “Other Tube” in the Airway

Comparison of Video Laryngoscopy and Direct Laryngoscopy in a Critical Care Transport Service

Objective. We evaluated video laryngoscopy (VL) (C-MAC, Karl Storz, Tuttlingen, Germany) for use in a critical care transport system. We hypothesized that the total number of airway attempts would decrease when using a video laryngoscope versus use of direct laryngoscopy (DL). Methods. We performed a nonrandomized group-controlled trial where six aircraft were outfitted with VL and the remainder utilized DL responding to a mix of scene runs and interfacility transports. Our primary outcome measure was the number of intubation attempts. We also compared the first-pass success (FPS) rates, laryngoscopic grades, and frequencies of rescue device use (including utilization of surgical airways) between VL and DL. Results. Crews intubated 348 patients with VL and 510 with DL. Successful endotracheal intubation within three attempts occurred 97.6% (confidence interval [CI] 96.5–98.6) of the time. The FPS rate was 85.8% (CI 83.4–88.1). In this cohort of patients, VL did not differ from DL with respect to total number of airway attempts (1.17 [CI 1.11–1.22] vs. 1.16 [CI 1.12–1.20]), FPS rate (85.6% [CI 82–89%] vs. 86.1% [CI 83-89]), or use of rescue airways (2.6% vs. 2.2%). The laryngoscopic view was superior in the VL group relative to the DL group (median Cormack-Lehane grade 1 [interquartile range (IQR) 1, 2] vs. 2 [IQR 1, 2]). Conclusion. VL using the C-MAC video laryngoscope did not reduce the total number of airway attempts or improve intubation compared with DL in a system of highly trained providers.

Videolaryngoscopy: should it replace direct laryngoscopy? a pro-con debate

Although it is universally recognized that the advent of videolaryngoscopy has revolutionized airway management, there is considerable disagreement over the future role of direct laryngoscopy and whether direct laryngoscopy should be relegated to a legacy technique. Arguments against the continued relevance of traditional intubation methods include increased success and decreased complications when videolaryngoscopy is utilized, as well as the fact that videolaryngoscopy enhances the performance of nonanesthesia providers. However, proponents of direct laryngoscopy cite technical issues, as well as instances in which intubation by videolaryngoscopy fails despite successful visualization. This argument serves as the rationale for the continued use of direct laryngoscopy, particularly for airway management experts.

Quest for an Ideal Intubating Device

Quest for an Ideal Intubating Device

Airway management in cervical spinal cord injured patients: a survey of European emergency physiciansʼ clinical practice

No European airway management guidelines are currently specific to patients with cervical spinal cord injury (CSCI). The objectives of this study were to determine the clinical practice of European emergency physicians and anaesthesiologists regarding airway management in patients with CSCI. A questionnaire survey was completed by the participants of the fourth European Congress on Emergency Medicine regarding the preferred intubation techniques and the relevant skills, as well as airway management manoeuvres that, in the physician's opinion, caused the least and the greatest cervical spine movement. A total of 115 questionnaires from physicians from 15 European countries were returned. The most preferred techniques for tracheal intubation in patients with CSCI were the use of direct laryngoscopy, awake nasal intubation with a fibreoptic bronchoscope, and the use of the intubating and standard laryngeal mask airway, in descending order. Not all emergency physicians were skilled in an alternative intubation technique to direct laryngoscopy, in contrast to the anaesthesiologists, who were all familiar with at least the standard laryngeal mask airway. More than half of the physicians considered that the fibreoptic bronchoscope provided the least cervical spine movement. However, most of the physicians who indicated the use of the fibreoptic bronchoscope as their preferred technique, were not skilled in its use. Furthermore, two-thirds of the respondents did not recognise that mask ventilation causes considerable cervical spine movement. Emergency physicians need better training in airway management to anticipate problems in patients with CSCI.

Is It the Validation or Invalidation of the Airway Management Algorithm?

Veterans Affairs Medical Center and Saint Louis University, St. Louis, Missouri. govind_r@hotmail.comThe authors must be congratulated for undertaking the study attempting to answer the question of protocol-based airway management in the event of unanticipated difficult intubation.1However, this raises some serious questions about the content and conclusions of the study.First, we are unclear as to how the investigators have concluded that their local protocol-based approach to airway management in the event of unanticipated difficult intubation after induction is efficacious. In an 18-month interval, 100 patients who were anticipated to be easy to intubate on preoperative work-up were subsequently found to be difficult to intubate. Sixteen percent of these patients suffered severe hypoxemia. Although the authors have not provided any data regarding the incidence of hypoxemia at induction among the true positive participants, it is unlikely that the incidence in that population could be as high as 16%. One patient suffered significant dental trauma and one ended up aspirating gastric contents. In addition, 89 patients were subjected to multiple attempts at direct laryngoscopy. The authors fail to acknowledge that these adverse events could very well been the result of the sticking with the proposed airway algorithm. It appears that most of the patients suffered hypoxemia as a result of multiple attempts at laryngoscopy. Hypoxemia, as we understand, is a clear sign of ventilatory failure under these situations unless it is attributable to other causes. Failure to keep a substantial number of patients oxygenated highlights the inefficiency of the proposed algorithm. Unless the study was designed to evaluate the efficacy of the Intubating Laryngeal Mask Airway ™ (LMA North America, Inc., San Diego, CA) as a tool for rescue ventilation, the conclusion that 100 percent of the patients were successfully ventilated underestimates the significant problems at ventilation encountered by the anesthesiologists while following the algorithm.We are also unclear on what basis the authors claim that the study has validated the local protocol-based approach to airway management. The study has neither the design nor the power to answer this question, as we do not know what would happen if the anesthesiologist were not restricted by the protocol to the use of direct laryngoscopy, gum elastic bougie, Intubating Laryngeal Mask Airway ™, or the transtracheal jet ventilation. Whether anticipated or unanticipated, the approach to airway management in the event of failed intubation at induction depends on multiple factors. The result of preliminary laryngoscopy, the view of the glottis, the primary reason for intubation failure (is it the poor laryngoscopic view or the failure to pass the tube?), ease of ventilation with the mask, the muscle relaxant used, emergency or elective surgery, state of oxygenation of the patient, presence or absence of risk factors for aspiration, the condition of upper dentition, and, above all, the skill and expertise of the anesthesiologist all must be taken into account before defining the next step. A protocol-based approach like the one proposed by the investigators may limit anesthesia providers from applying individual problem-based solutions in the event of inadvertent difficult intubation. The end result: the patient with the poor dentition suffers dental trauma, the patient with full stomach may wind up aspirating gastric contents; failure of the Intubating Laryngeal Mask Airway ™ regardless of the cause (morbid obesity/limited mouth opening) commits the anesthesia provider to expose the patient to the risk of transtracheal jet ventilation although switching to simple a laryngeal mask airway or laryngeal tube might have solved that problem. A broad-based protocol that incorporates all the fundamental goals and objectives of airway management, e.g. , the American Society of Anesthesiologists airway protocol, allowing for stepwise evaluation based interventions while taking into account factors specific to operator skill and experience, available resources, and patient continues to be the most prudent approach to management of inadvertent difficult intubation.2Veterans Affairs Medical Center and Saint Louis University, St. Louis, Missouri. govind_r@hotmail.com

Cytologic diagnosis of laryngeal diseases

The cytology of laryngeal diseases including 25 cases of laryngeal carcinoma, 15 cases of vocal cord polyp, 8 cases of chronic laryngitis and 2 cases of laryngeal leukoplakia were studied.The results were as follows;1. The over all correct diagnostic rate in this series of patients was 77.6%.2. The accuracy of cytological diagnosis in laryngeal carcinomas was 76.0% and the false negative rate was 24.0%.3. All benign laryngeal diseases were proved cytologically benign and the false positive was none.4. The laryngeal cytology under direct laryngoscopy were superior to the cytology under indirect laryngoscopy.5. The false negative diagnosis were derived by the paucity of malignant cells and epithelial cells in the specimen.6. The exfolliative cytology was proved to be a usefll method for the diagnosis of laryngeal diseases.7. The accuracy of laryngeal cytology should be improved with the use of direct laryngoscopy, especially with fiberlaryngoscopy.