Video Laryngoscope Research Articles

Changes in practice of less-invasive surfactant administration (LISA) in United Kingdom neonatal units.

To determine whether the use of less-invasive surfactant administration (LISA) had changed between 2018 and 2024. An online questionnaire was sent to all 191 neonatal units between June 2023 and May 2024. One consultant from each neonatal unit was randomly selected. Follow-up was done by telephone (middle-grade doctor grade and above or alternatively to Advanced Neonatal Nurse Practitioners) for the non-responders. Response rate was 100%from 191 units neonatal units. LISA was used in 134 (70%) neonatal units in 2024 compared to 35 (18.7%) units in 2018 (p < 0.001). The reason why LISA was not performed was lack of experience/training (51%) or not having a standardised practice/guideline (49%). LISA in the delivery suite (DS) had increased from 2% in 2018 to 16% in 2024, and the use of video laryngoscope for LISA is becoming standard of practice. The oxygen requirement criteria for the use of LISA in both the DS and on neonatal unit had reduced to FiO2 of 0.3 or more. The uptake of LISA had increased in the United Kingdom. There is greater use of LISA in the DS. Lack of training and expertise were the major limiting factors for LISA not being performed.

Evaluating the Impact of Direct, Direct Video, and Indirect Video Laryngoscopy Training on the Proficiency of Medical Students in Performing Direct Laryngoscopy: A High-Fidelity Manikin-Based Assessment.

Endotracheal intubation (ETI), a potentially lifesaving intervention employed frequently in the emergent setting, is a manual skill that improves with repetitive practice and high-quality feedback. Classically, ETI centered around Direct Laryngoscopy (DL); however, with the advent and recent availability of Indirect Video Laryngoscopy (IVL) and Direct Video Laryngoscopy (DVL), studies have demonstrated varying results on the benefit of Video Laryngoscopy (VL) in training. We hypothesize that a training program centered on DVL, allowing students to visualize the anatomy and simultaneously receive instructor feedback via a real-time video feed, will practically improve student performance in DL. Our study of first-year medical students from the Edward Via College of Osteopathic Medicine (n = 21) randomized participants to one of three cohorts: DL, IVL, and DVL in a manikin-based simulation laboratory evaluated on successful intubation, time to successful intubation, dental injury, Numeric Rating Scale (NRS) to assess the trainee's perception of their performance and confidence level of performing intubation in a real-life scenario. Our results did not demonstrate a statistically significant difference between the three training modalities based on the outcomes assessed. Although IVL and DVL cohorts achieved 100% success following training, compared to 71% in the DL cohort, the results were not statistically significant. This is potentially due to our limited sample size, as our sample did not meet the calculated 162 participants for 80% power. These findings suggest that a larger sample size may be required to determine if there is a significant difference in outcomes for these training modalities.

Video laryngoscopy may improve the intubation outcomes in critically ill patients: a systematic review and meta-analysis of randomised controlled trials

BackgroundThe role of video laryngoscopy in critically ill patients requiring emergency tracheal intubation remains controversial. This systematic review and meta-analysis aimed to evaluate whether video laryngoscopy could improve the clinical...

A Comparative Study between C-MAC Video-Laryngoscope and Fiberoptic Laryngoscope in Anticipated Difficult Intubation

Abstract Background Numerous indirect laryngoscopes have been introduced into clinical practice and compared with the Macintosh laryngoscope. Most studies have described a significantly better glottic view and a higher success rate in difficult tracheal intubations for the indirect laryngoscopes. Some case reports also describe the successful use of these tools under sedation with preserved spontaneous breathing. Objective To compare the C-MAC® D-Blade video laryngoscope and the flexible fiberoptic scope for intubation of patients with anticipated difficult intubation. The primary endpoint was the time to achieve successful tracheal intubation. Secondary endpoints included glottic view at intubation and the number of intubation attempts. The study was conducted on 60 patients at the operating theatres of Ain Shams University Hospitals. Patients and Methods After obtaining approval from the Research Ethical Committee, Faculty of Medicine, Ain Shams University and informed consents from patients, 60 American Society of Anaesthesiologists I-II adult patients with El-Ganzouri risk index score (EGRI) ≥ 4 (age range, 21- 60 years) undergoing elective surgeries requiring tracheal intubation were enrolled in this prospective study at the operating theaters of Ain Shams University Hospitals from March 2022 to October 2022. Results Our results showed Duration of intubation (s) among the study groups. Duration of intubation (s) in Video laryngoscope Group ranged from 22 to 34 seconds with mean ± SD = 27.87 ± 3.74 while in Fiberoptic Group the Duration of intubation (s) ranged from 60 to 75 seconds with mean ± SD = 66.77 ± 4.24 with highly statistically significant difference (p = &amp;lt;.001) between the two groups and showed POGO score among the study groups. Regarding POGO score, there was a significant difference between the two studied groups (p = 0.019). C-MAC video laryngoscope had become a good alternative and was associated with visualization of laryngeal structures in shorter time as compared to traditional flexible fiberoptic laryngoscopy. Conclusion This randomized, prospective study demonstrated that the C-MAC may offer an advantage over the fiberoptic laryngoscope with respect to the time required to obtain a clear glottic view and successful placement of the tracheal tube. However, the Flexible Fiberoptic Scope offered a better visualization of the glottic opening compared to the C-MAC video laryngoscope. The use of C-MAC as a usual tool was limited as it is expensive device, and the use of fiberoptic bronchoscope needs more experience and training.

A Rare Case of Uvulitis Following Endotracheal Intubation Using C- Mac Videolaryngoscope and How To Avoid It

Uvular injuries are uncommon after general anesthesia and can result from direct trauma to the posterior part of the soft palate or compression and restriction of blood flow to the uvula caused by the inadvertent placement of the airway or suction devices in the oral cavity. There have been cases of inflammation and ulceration occurring in the midline oropharyngeal structures such as the uvula after general anesthesia with a tube or laryngeal mask airway, even in the absence of direct trauma or infection, presumably due to compression ischemia. While sore throat following general anesthesia is a common symptom, it is important to evaluate any severe or persistent pain to exclude uvulitis. Here we present a case of uvulitis that developed after the insertion of a flexometallic endotracheal tube using the midline technique during C-Mac video laryngoscopy. We also emphasize the measures that can be implemented to prevent such a complication. The entrapment of the uvula during intubation often goes unnoticed due to limited oral space after insertion of the video laryngoscope blade, with the intubating anesthetist staying focused on the monitor. This complication following the use of a C-Mac video laryngoscope has not been previously documented.

Application of computational fluid dynamics to investigate pathophysiological mechanisms in exercise-induced laryngeal obstruction.

The underlying pathophysiological mechanisms of exercise-induced laryngeal obstruction (EILO) remain to be fully established. It is hypothesized that high inspiratory flow rates can exert a force on laryngeal airway walls that contribute to its inward collapse causing obstruction. Computational fluid dynamics (CFD) presents an opportunity to explore the distribution of forces in a patient-specific upper airway geometry. The current study combined exercise physiological data and CFD simulation to explore differences in airflow and force distribution between a patient with EILO and a healthy matched control. Participants underwent incremental exercise testing with continuous recording of respiratory airflow and laryngoscopic video, followed by an MRI scan. The respiratory and MRI data were used to generate a subject-specific CFD model of upper respiratory airflow. In patient with EILO, the posterior supraglottis experiences an inwardly directed net force, whose magnitude increases nonlinearly with larger flow rates, with slight changes in the direction toward the center of the airway. The control demonstrated an outwardly directed force at all regions of the wall, with a magnitude that increases linearly with larger flow rates. A comparison is made between the CFD results and endoscopic visualization of supraglottic collapse, and a very good agreement is found. The current study presents the first hybrid physiological and computational approach to investigate the pathophysiological mechanisms of EILO, with preliminary findings showing great potential, but should be used in larger sample sizes to confirm findings.NEW & NOTEWORTHY The current study is the first to use a hybrid combined computational fluid dynamics (CFD) and exercise physiology approach to investigate pathophysiology in exercise-induced laryngeal obstruction (EILO). The hybrid methodology is a promising approach to explore the pathophysiological mechanisms underlying the condition. Notable differences occur in the distribution of airflow and wall forces between the EILO and control participants, which align with symptoms and visual observations.

Outcomes of tracheal resection and anastomosis in patients with tracheal stenosis: a clinical perspective

BackgroundTracheal stenosis results from an altered inflammatory response to mucosal damage, which leads to impairment of breathing and can even be fatal if not treated promptly (Ind J Otolaryngol Head Neck Surg 73(4):447–454, 2020). ENT and head and neck surgeons face difficulties while treating tracheal stenosis. Mechanical stress from extended endotracheal intubation or tracheostomy, combined with hypoxic metabolic disturbances during an underlying event, is the most frequent cause of tracheal stenosis (Al-Azhar Int Med J 3(10):149-57, 2022). The main objective of the study is to assess the outcomes of tracheal resection and anastomosis in patients who presented with tracheal stenosis. This emphasizes the need for proper case selection and timely surgical intervention to relieve the airway obstruction and to ensure the effectiveness of tracheal resection and anastomosis as the less morbid approach by avoiding a midline sternotomy.The study was conducted in a tertiary care center on 25 patients who were admitted in ENT ward from the year 2011 to year 2021. Case records of those patients who underwent tracheal resection and anastomosis were analyzed on a retrospective basis. Detailed history taking and clinical examination with appropriate investigations like flexible bronchoscopy, computed tomography with 3-dimensional reconstruction, video laryngoscopy, direct laryngoscopy, and lung function tests were carried out for all the patients in the study as required. An evaluation of GERD was also done. Appropriate surgical procedure was done with regular post-operative follow-up for 18 months.ResultsIn our study, 92% of patients had satisfactory outcomes following tracheal resection and anastomosis, while some patients experienced minor complications. In 8% of patients, the primary surgery failed, among whom one patient underwent revision surgery and is doing well. The other patient with post-traumatic stenosis with a long stenotic segment underwent Shiann Yann Lee procedure in an outside center which resulted in failure following which T tube insertion was done. The patient showed improvement and was decannulated after a month.In our study of 25 patients with tracheal stenosis, postoperative complications occurred and were managed accordingly. However, there was no significant correlation between these complications and patient age, sex, extent of stenosis, preoperative Cotton-Myer grading, or the type of surgical procedure performed. This lack of correlation may be attributed to the limited sample size.ConclusionTracheal resection and anastomosis are challenging procedures and should be done only in centers with experience. Standard treatment consists of resection of the stenotic segment with end-to-end anastomosis. The geometry of the ends to be anastomosed is matched properly to avoid gaps or weak points and for air-tight seal anastomosis.

Assessment of an Airway Curriculum in a Pulmonary and Critical Care Fellowship Program.

Endotracheal intubations (EIs) in the intensive care unit are high-risk procedures often performed by pulmonary and critical care medicine (PCCM) providers. The Accreditation Council for Graduate Medical Education mandates PCCM fellows' competency in this procedure; however, the learning experiences vary across programs. After conducting a needs assessment, we developed a curriculum unique to our institution to supplement our fellows' existing EI experiences in the operating room and the intensive care unit. To assess the curriculum's short-term objectives: knowledge acquisition, maintenance, and practical skills 1 year after participation. We administered a survey to the graduating PCCM fellows for two consecutive years. We designed the comprehensive airway curriculum to include didactic lectures and simulation-based education. The knowledge acquisition and maintenance were measured by administering a 26-question knowledge survey before and after curriculum participation and after 1 year. The fellows also received a practical examination 1 year after participation. To compare knowledge survey scores, we used paired t tests and permutation tests. In the needs assessment, 56% of graduating fellows believed they were proficient in performing EI, whereas 33% were undecided and 11% believed they were unprepared. Most believed they would need more than two courses after graduation to be confident in independently performing EIs. Most will only occasionally have backup for EI from anesthesiology or emergency medicine in their future jobs. One identified barrier to learning EI was the lack of a formal curriculum. In the knowledge assessment, nine first-year fellows participated in the curriculum. The cohort's mean presurvey score was 13.0 (standard deviation [SD], 4.5) versus 18.6 (SD, 3.6) mean postsurvey score. One year after participation, the mean survey score was 17 (SD, 1.2). The postsurvey and 1-year postparticipation survey scores were significantly higher than the presurvey scores (P < 0.05). One year after participation, the practical examination showed most fellows retained skills in EI using ramped position, video and direct laryngoscopy, bag-mask ventilation, and oropharyngeal airway placement. The airway curriculum enhances fellows' knowledge acquisition and maintenance 1 year after participation. The practical examination 1 year after participation highlighted the skills retained and those still needing improvement.

Investigation Methods for Vocal Onset-A Historical Perspective.

The topic of phonation onset gestures is of great interest to singers, acousticians, and voice physiologists alike. The vocal pedagogue and voice researcher Manuel Garcia, in the mid-19th century, first coined the term "coup de la glotte". Given that Garcia defined the process as "a precise articulation of the glottis that leads to a precise and clean tone attack", the term can certainly be linked to the concept of "vocal onset" as we understand it today. However, Garcia did not, by any means, have the technical measures at his disposal to investigate this phenomenon. In order to better understand modern ways of investigating vocal onset-and the limitations that still exist-it seems worthwhile to approach the subject from a historical perspective. High-speed video laryngoscopy (HSV) can be regarded as the gold standard among today's examination methods. Nonetheless, it still does not allow the three-dimensionality of vocal fold vibrations to be examined as it relates to vocal onset. Clearly, measuring methods in voice physiology have developed fundamentally since Garcia's time. This offers grounds for hope that the still unanswered questions around the phenomenon of vocal onset will be resolved in the near future. One promising approach could be to develop ultra-fast three-dimensional MRI further.

Insights into obstetric anesthesia practices: a quantitative survey among physicians across Arab countries

BackgroundObstetric anesthesia guidelines are essential for standardizing obstetric anesthesia practices globally and ensuring high-quality patient care. However, practices may vary across different settings, and there are limited data from Arab countries. This study aims to gain insights into obstetric anesthesia practices in several major hospitals across Arab countries.MethodsA questionnaire was emailed to 85 obstetric anesthesiologists/anesthesia chairpersons in major hospitals, including academic medical institutions and central hospitals, across 11/22 Arab countries. This survey gathered data on key structural and process-related obstetric anesthesia indicators.ResultsOut of 85 contacted, we had 56 responses (65.8%), with 41 being fully completed, providing insights into obstetric anesthesia indicators. Regarding structure: 31 (76%) hospitals had an operating room adjacent to the delivery room, all had intensive care units, and 22 (54%) had a lead obstetric anesthesiologist. For equipment, 19 (46%) had a video laryngoscope in the delivery suite, and 20 (49%) occasionally used ultrasound for epidurals. Regarding process: 33 (81%) held regular meetings, and 21 (51%) conducted research. Before epidural and spinal procedures, 26 (63%) and 28 (68%) required coagulation studies for patients without a history of hemorrhagic complications, while 38 (93%) and 36 (88%) mandated a platelet count, respectively. For labor analgesia, 34 (83%) primarily used epidurals, and 15 (37%) placed preemptive catheters in high-risk pregnancies. For cesarean delivery, 40 (98%) used spinals, with 16 (39%) using intrathecal morphine and 22 (54%) administering aspiration prophylaxis before general anesthesia. Regarding spinal-induced hypotension, 6 (15%) used prophylactic phenylephrine infusion.ConclusionThis survey highlights variations in obstetric anesthesia practices among various major hospitals in several Arab countries, compared to international recommendations. It emphasizes the need for obstetric anesthesia registries in the Arab world for future research. Further studies are required to outline country-specific practices, improve resource allocation, and enhance obstetric population safety and satisfaction.

Role of reflux symptom index score in diagnosis of laryngopharyngeal reflux

Background: The retrograde flow of gastric contents to the upper aero digestive tract is known as laryngo pharyngeal reflux disease (LPRD). Diet and lifestyle play a huge role in the pathophysiology of LPR. Methods: A hospital based cross sectional study in the Department of ENT, KMCT, Kozhikode. 291 Patients were selected from those who presented to the OPD with throat symptoms who scored &gt;10 in a questionnaire (Reflux symptom Index) that was provided and were advised to undergo video laryngoscopy and their reflux finding score (RSI)was calculated. LPRD prevalence, RSI/Reflux Findings Score (RFS) correlations, and clinical/ laryngoscopic (video laryngoscopy) associations were analyzed. Results: LPRD prevalence was 68.7%, higher in females (60.1%) and the 41-50 age group (31.3%). Increased spicy food/caffeine intake and shorter dinner-bedtime intervals were significantly associated. Heartburn/indigestion was the most common symptom, with RSI mean 12.94±2.26. Erythema/hyperaemia was the most frequent laryngeal finding, with RFS mean 8.47±2.40. RSI and RFS scores significantly correlated. Conclusions: This study demonstrates a high LPRD prevalence among patients with throat symptoms, particularly in females aged 41-50 and influenced by dietary/lifestyle factors. RSI effectively identified LPRD in this resource-constrained setting, highlighting its diagnostic value. These findings provide valuable insights for managing and further investigating LPRD.

Acute Supraglottitis Causing Airway Obstruction in Adults - A Case Series.

Acute adult supraglottitis is a serious and potentially life-threatening condition marked by inflammation of the supraglottic structures, posing a significant risk for rapid airway compromise. This case series highlights the varied presentations and management challenges associated with adult supraglottitis. The four cases involve adult males, most with uncontrolled diabetes mellitus, presenting with symptoms such as difficulty breathing, sore throat, dysphagia, and voice changes. Diagnostic approaches included soft-tissue neck radiographs and video laryngoscopy, with common findings of an edematous epiglottis and "thumbprint" sign. Management strategies ranged from conservative treatment with antibiotics and steroids to emergent airway interventions like tracheostomy. These cases underscore the importance of early diagnosis, close monitoring, and tailored treatment to prevent severe outcomes. The series emphasizes the need for high clinical suspicion and prompt action in cases of adult supraglottitis, especially given its potential for rapid deterioration and significant morbidity.

Comparing the effectiveness and safety of videolaryngoscopy and direct laryngoscopy for endotracheal intubation in the paediatric emergency department: a systematic review and meta-analysis.

Endotracheal intubation is an uncommon procedure for children in the emergency department but can be technically difficult and cause significant adverse effects. Videolaryngoscopy (VL) offers improved first-pass success rates over direct laryngoscopy (DL) for both adults and children undergoing elective surgery. This systematic review was designed to evaluate current evidence regarding how the effectiveness and safety of VL compares to DL for intubation of children in emergency departments. Four databases (MEDLINE, Embase, CENTRAL and Web of Science) were searched on 11th May 2023 for studies comparing first-pass success of VL and DL for children undergoing intubation in the emergency department. Studies including adult patients or where intubation occurred outside of the emergency department were excluded. Quality assessment of included studies was carried out using the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I) tool. Meta-analysis was undertaken for first-pass success and adverse event rate. Ten studies met the inclusion criteria representing 5,586 intubations. All included studies were observational. Significantly greater first-pass success rate was demonstrated with VL compared to DL (OR 1.64, 95% CI [1.21-2.21], p = 0.001). There was no significant difference in risk of adverse events between VL and DL (OR 0.79, 95% CI [0.52-1.20], p = 0.27). The overall risk of bias was moderate to serious for all included studies. VL can offer improved first-pass success rates over DL for children intubated in the emergency department. However, the quality of current evidence is low and further randomised studies are required to clarify which patient groups may benefit most from use of VL. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=415039, Identifier CRD42023415039.

Direct Laryngoscopy Versus Video Laryngoscopy for Intubation in Critically Ill Patients: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Trials.

Given the uncertainty regarding the optimal approach to laryngoscopy for the intubation of critically ill adult patients, we conducted a systematic review and meta-analysis to compare video laryngoscopy (VL) vs. direct laryngoscopy (DL) for intubation in emergency department and ICU patients. We searched MEDLINE, PubMed, Embase, Cochrane Library, and unpublished sources, from inception to February 27, 2024. We included randomized controlled trials (RCTs) of critically ill adult patients randomized to VL compared with DL for endotracheal intubation. Reviewers screened abstracts, full texts, and extracted data independently and in duplicate. We pooled data using a random-effects model, assessed risk of bias using the modified Cochrane tool and certainty of evidence using the Grading Recommendations Assessment, Development, and Evaluation approach. We pre-registered the protocol on PROSPERO (CRD42023469945). We included 20 RCTs (n = 4569 patients). Compared with DL, VL probably increases first pass success (FPS) (relative risk [RR], 1.13; 95% CI, 1.06-1.21; moderate certainty) and probably decreases esophageal intubations (RR, 0.47; 95% CI, 0.27-0.82; moderate certainty). VL may result in fewer aspiration events (RR, 0.74; 95% CI, 0.51-1.09; low certainty) and dental injuries (RR, 0.46; 95% CI, 0.19-1.11; low certainty) and may have no effect on mortality (RR, 0.97; 95% CI, 0.88-1.07; low certainty) compared with DL. In critically ill adult patients undergoing intubation, the use of VL, compared with DL, probably leads to higher rates of FPS and probably decreases esophageal intubations. VL may result in fewer dental injuries as well as aspiration events compared with DL with no effect on mortality.

Comparison of Three Tracheal Intubation Procedures Using Personal Protective Equipment, Direct and Video Laryngoscopes: An Open, Randomized, Parallel Clinical Trial

Background: During the COVID-19 pandemic, severe respiratory failure is a life-threatening condition, and life-saving tracheal intubation is a high-risk aerosol- and droplet-generating procedure. It is crucial to protect healthcare workers without compromising patient safety during intubation. The use of personal protective equipment (PPE) and different types of laryngoscopes are measures to reduce the risk of infectious transmission that might impact the intubation process. Objectives: This study aimed to evaluate the effects of different levels of PPE and types of laryngoscopes on the duration of the intubation process and its success rate. Methods: We conducted an open, randomized, parallel clinical trial on non-COVID-19 adult patients scheduled for elective and emergency surgeries under general anesthesia from November 2021 to May 2022. Patients were divided into three groups: Group 1 was intubated using a video-guided laryngoscope with operators wearing level three PPE; group 2 was intubated using a direct laryngoscope with operators wearing level three PPE; and group 3 was intubated using a direct laryngoscope with operators wearing level two PPE. Intubation was performed by 2nd- and 3rd-year anesthesia residents. Results: The duration of intubation varied significantly among the groups, with Group 1 taking the longest time (P = 0.046). Group 3 had a higher success rate for first-attempt intubation (P = 0.056). Conclusions: The use of PPE and video-guided laryngoscopy had varying effects on the intubation procedure, with the most notable impact being on the overall length of intubation. Further research with a larger sample size is needed to validate these findings.

A Comparison of Conventional Rotating Method and Non-Rotating Method for Double-Lumen Tube Insertion Using a Customized Rigid J-Shaped Stylet for One-Lung Ventilation: A Randomized Controlled Trial.

Background: The conventional double-lumen tube (DLT) insertion method requires a rotatory maneuver that was developed using direct laryngoscopy and may not be optimal for video laryngoscopy. This study compared a new non-rotatory maneuver with the conventional method for DLT insertion using video laryngoscopy. Methods: Patients scheduled for thoracic surgery requiring one-lung ventilation were randomly assigned to either the rotating (R) or non-rotating (NR) method groups. All patients were intubated using a customized rigid J-shaped stylet, a video laryngoscope, and a left-sided silicone DLT. The conventional rotatory maneuver was performed in the R group. In the NR group, the stylet was inserted with its tip oriented anteriorly (12 o'clock direction) while maintaining the bronchial lumen towards the left (9 o'clock direction). After reaching the glottic opening, the tube was inserted using a non-rotatory maneuver, maintaining the initial orientation. The primary endpoint was the intubation time. Secondary endpoints included first-trial success rate, sore throat, hoarseness, and airway injury. Results: Ninety patients (forty-five in each group) were included. The intubation time was significantly shorter in the NR group compared to the R group (22.0 [17.0, 30.0] s vs. 28.0 [22.0, 34.0] s, respectively), with a median difference of 6 s (95% confidence interval [CI], 3-11 s; p = 0.017). The NR group had a higher first-attempt success rate and a lower incidence of sore throats. Conclusions: The non-rotatory technique with video laryngoscopy significantly reduced intubation time and improved first-attempt success rate, offering a viable and potentially superior alternative to the conventional rotatory technique.

Comparative Analysis of Hemodynamic Responses and Oropharyngeal Complications in Tracheal Intubation: Evaluating Conventional, Video, and Rigid Video Laryngoscopes Under General Anesthesia.

BACKGROUND This study aimed to compare the hemodynamic changes and the occurrence of oropharyngeal complications among patients undergoing tracheal intubation with an ordinary laryngoscope, video laryngoscope, and rigid video laryngoscope under general anesthesia. MATERIAL AND METHODS Patients undergoing elective tracheal intubation under general anesthesia were prospectively enrolled as study subjects. Hemodynamic indicators such as diastolic blood pressure (DBP), systolic blood pressure (SBP), mean arterial pressure (MAP), and heart rate (HR), as well as the incidences of oropharyngeal complications, including dental injury, oral mucosal injury, hoarseness, sore throat, and dysphagia, were observed in the patients of 3 groups (group A: ordinary laryngoscope, group B: video laryngoscope, group C: rigid video laryngoscope). Observations were made after anesthesia induction (T₀), immediately after tracheal intubation (T₁), and at 5 min after intubation (T₂). RESULTS The HR at T1 in group A was significantly higher than in groups B and C (P<0.05). However, the difference in the number of tracheal intubations was statistically significant among the 3 groups (P<0.05); group C exhibited the highest first-time success rate of tracheal intubation (95%), whereas group A had the highest failure rate (5%). Significant differences were also noted in the incidences of oral mucosal injury and sore throat among the groups (P<0.05), with the highest incidence in group A and the lowest in group C. CONCLUSIONS Compared with the ordinary laryngoscope, tracheal intubation using a video or rigid video laryngoscope results in milder hemodynamic impacts and fewer intubation-related complications. The rigid video laryngoscope may be safer and more effective.

C-MAC Video Stylet Assisted Endotracheal Intubation in Sedated but Spontaneously Breathing Patients Using Remimazolam and Trachospray Device: A Report of Two Cases

The C-MAC video stylet (Karl Storz KG, Tuttlingen, Germany) is proposed as a successor to the familiar retromolar intubation endoscope. With its flexible tip, it may be especially useful for patients with a limited mouth opening. An awake or sedated airway management technique is often preferred when a difficult airway is anticipated. Due to the challenges in preparation, sedation, topical airway anesthesia and the execution of such an airway management technique itself, these techniques are often clinically underused. The C-MAC video stylet seems to be well suited for an awake or sedated airway approach, as its handling is easier and faster than a flexible fiberscope. It does not exert pressure on the tongue as direct laryngoscopy or video laryngoscopy do. We report two cases of a difficult airway in which intubation was performed by using the C-MAC video stylet in sedated, spontaneously breathing patients. After a low dose of 3 mg midazolam IV, remimazolam was administered continuously (0.46–0.92 mg/kg/h). This was supplemented with a low dose of remifentanil (0.04–0.05 µg/kg/min). The Trachospray device (MedSpray Anesthesia BV, Enschede, The Netherlands) was used for topicalization of the upper airway by means of 4 mL of lidocaine 5%. In addition, a further 5 mL of lidocaine 5% was sprayed via an epidural catheter advanced through the oxygenation port of the C-MAC video stylet for further topicalization of the vocal cords and proximal part of the trachea. The well-coordinated steps described in these two cases may represent a blueprint and a good starting point for future studies with a larger number of patients.

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

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

Comparing Air Medical Personnel Intubation Success Rates Using Direct, Channeled Video-Assisted, and Unchanneled Video-Assisted Laryngoscopy

ObjectiveThe aim of this study was to determine the first-pass intubation success rates of air medical providers using direct laryngoscopy, channeled blade video laryngoscopy, and nonchanneled blade video laryngoscopy. MethodsThis was a retrospective cohort study of the Orlando Health Air Care Team (ACT) airway quality registry over a 5-year period. The ACT had 3 approved approaches for endotracheal intubation: direct laryngoscopy, the King Vision (Ambu, Ballerup Denmark) channeled blade laryngoscope, or the C-MAC (Karl-Storz, Tuttlingen Germany) (nonchanneled) laryngoscope. The main outcome was the first-pass success rate. The secondary outcomes included the number of attempts, the overall success rate, and complications. ResultsOf 517 intubations, 312 were performed with direct laryngoscopy, 126 with a channeled video laryngoscope, and 79 with a nonchanneled laryngoscope. The mean number of attempts was 1.26, and the overall success rate was 93%. Use of the nonchanneled video laryngoscope had a higher first-pass success rate than direct or channeled laryngoscopy (92% vs. 76% and 78%, P = .006), required fewer attempts (1.09 [95% confidence interval (CI), 1.01-1.17] vs. 1.29 [95% CI, 1.23-1.35] and 1.28 [95% CI, 1.18-1.38], P < .001), and a higher overall success rate for intubation (99% vs. 90% and 95%, P = .018). ConclusionThe use of a nonchanneled video laryngoscope provided higher first-pass success rates, fewer total attempts, and higher overall success rates.