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The McGrath series 5 video laryngoscope with its handle mounted display and angulated blade design. The position of the disposable blade can be placed on the camera stick in three different positions (photo courtesy of Aircraft Medical Limited)
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The incidence of difficult direct intubation in the intensive care unit (ICU) is estimated to be as high as 20%. Recent advances in video-technology have led to the development of video laryngoscopes as new intubation devices to assist in difficult airway management. Clinical studies indicate superiority of video laryngoscopes relative to conventio...
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Background
The 2022 ASA guidelines recommend the video laryngoscope, video stylet, and flexible videoscope as airway management tools. This study aims to compare the efficacy of three airway devices in intubating patients with difficult airways.
Methods
A total of 177 patients were selected and randomized into the following three groups: the video...
INTRODUCTION:
Tracheal intubation causes a haemodynamic response that might be harmful for patients. The Airtraq® laryngoscope has been shown to decrease the haemodynamic response to single-lumen tube intubation. We hypothesised that double-lumen bronchial tube placement with the Double-lumen Airtraq® laryngoscope would cause a reduced haemodynami...
Accurate endotracheal intubation for patients in extremis or at risk of physiologic decompensation is the gold standard for emergency medicine. Field intubation is a complex process and time to intubation, number of attempts, and hypoxia have all been shown to correlate with increases in morbidity and mortality. Expanding laryngoscope technology wh...
Background
Endotracheal intubation by direct laryngoscopy is a widely performed lifesaving technique. Although there are guidelines for optimal size and depth of insertion of an endotracheal tube (ETT) for successful intubation, there is no consensus on the point at which it should be held along its length. This will arguably affect the time, ease,...
Introduction:
Rapid sequence induction of anaesthesia is indicated in patients with an increased risk of pulmonary aspiration. The main objective of the technique is to reduce the critical time period between loss of airway protective reflexes and rapid inflation of the cuff of the endotracheal tube to minimise the chance of aspiration of gastric...
Citations
... The literature suggests that acute-angle blades should be reserved for predicted or known difficult airway situations, especially in patients with an anterior larynx [89]. Thus, the use of acute-angle VLs may be detrimental, in comparison to standard Macintosh-style blades, for the intubation of normal airways. ...
... Thus, the use of acute-angle VLs may be detrimental, in comparison to standard Macintosh-style blades, for the intubation of normal airways. One such reason is that acute-angle VLs only provide an indirect view and present with a sharp angle, resulting in the ETT needing to be introduced with a device such as a stylet to ensure it is able to be manipulated around the steep angle [89]. Thus, one limitation of the papers studied in this review is the comparison of acute-angle blades to Macintosh-style blades, as the clinical indication for each is different. ...
Videolaryngoscopes (VLs) have emerged as a safety net offering several advantages over direct laryngoscopy (DL). The aim of this study is to expand on our previous study conducted in 2016, to deduce which VL is most preferred by clinicians and to highlight any changes that may have occurred over the past 7 years. An extensive systematic literature review was performed on Medline, Embase, Web of Science, and Cochrane Central Database of Controlled Studies for articles published between September 2016 and January 2023. This review highlighted similar results to our study in 2016, with the CMAC being the most preferred for non-channelled laryngoscopes, closely followed by the GlideScope. For channelled videolaryngoscopes, the Pentax AWS was the most clinically preferred. This review also highlighted that there are minimal studies that compare the most-used VLs, and thus we suggest that future studies directly compare the most-used and -preferred VLs as well as the specific nature of blades to attain more useful results.
... The wide variety of videolaryngoscopes with different angulations, blade characteristics, and display properties have become commonly used airway gadgets in the operating room, intensive care units, and in emergency settings. [1][2][3] Studies which compare videolaryngoscopes with conventional laryngoscopy have established the effectiveness of videolaryngoscopes with respect to easier learning curve, better laryngeal view, and lesser haemodynamic disturbances. [4][5][6] Many custom made models are available and some are user friendly so that one can visualise the intubation in smart phones or laptops by connecting the camera using cables. ...
Background and aims:
Videolaryngoscopes with varying characteristics with regard to angulation of blades and video configurations are now available. However, the contribution of each of these in improving ease of intubation is quite different. We evaluated the role of video camera in the performance of laryngoscopy by using the universal serial bus (USB) videolaryngoscope in patients with predicted difficult airway.
Methods:
Sixty patients in the age group of 25 to 65 years having Mallampati grade III or IV were randomly allocated to two groups. All patients were American Society of Anesthesiologists physical status grade I or II and planned for elective surgical procedure under general anesthesia. USB videolaryngoscope or Macintosh laryngoscope was used for intubation as per group allotted. Comparison of time of endotracheal intubation was our primary outcome measure and it was calculated from the time the laryngoscope tip passes the incisors to the initial appearance of capnography wave. Rate of successful intubation, number of attempts needed for successful tube placement, optimisation manoeuvres used, changes in haemodynamic parameters and airway injuries were evaluated as secondary outcomes.
Results:
Time for intubation was shorter in the Macintosh group than the USB group (P = 0.024). The incidence of successful intubation was similar in both groups (P = 0.079). USB group required lesser number of attempts for tube placement (P = 0.047). The incidence of airway injuries was similar in both the groups.
Conclusion:
USB videolaryngoscope reduces the number of attempts required for successful endotracheal intubation compared to Macintosh laryngoscope though it increases the time for intubation in patients with predicted difficult airway.
... [3] For standard blade style videolaryngoscopes, the blade is inserted in the midline without sweeping the tongue laterally and the endotracheal tube is introduced from the right angle of the mouth. [4] While using videolaryngoscope, there is equal space on both sides for tube insertion. In our patient, when an attempt from the right side failed, inserting endotracheal tube from the left angle of the mouth with the left hand of the laryngoscopist provided a simple lifesaving solution. ...
... and 0.13-0.30% and can increase by 20% in other rooms such as the Intensive Care Unit (ICU) (4). Griesdale in his study found that the incidence of difficult intubation was 6.6% in the ICU of the Vancouver General Hospital (VGH) and 39% of patients experienced complications (5). ...
p> Objective . Airway management has undergone a dramatic transformation since the arrival of video laryngoscope (VL). VL has higher intubation success rate on first try and lower complications in comparison to direct laryngoscope (DL). The use of VL is recommended in intubating COVID-19 patients to speed up intubation time and reduce failure rate. A team from Airlangga University developed Wycope Video Laryngoscope (Wycope VL), a VL with Wi-Fi connection to smartphones for an easier VL with low cost. This study aimed to compare the effectiveness of Wycope VL, C-MAC Video Laryngoscope (C-MAC VL), and DL.
Materials and Methods . This study was an analytic observational study with a cross sectional design, involving 63 patients who were divided into 3 groups based on the type of laryngoscope, namely Wycope VL, C-MAC VL, and DL. Intubation is carried out by 4th year anaesthesiology resident. Research subjects were patients who will undergo elective surgery at Dr. Soetomo General Hospital under general anaesthesia using orotracheal tube. Inclusion age of 19-64 years, PS ASA 1-2, no anatomical abnormalities of the airway, did not have difficult airway, and was willing to participate in the study.
Results . All patients were successfully intubated without complications. C-MAC VL (5.33±1.42 seconds) and Wycope VL (5.95±0.74 seconds) was significantly faster in seeing vocal folds and glottis compared to DL (7.14±0.72 seconds) with P=0.000. DL was significantly faster in average time of intubation (15.52±5.90 seconds) compared to C-MAC VL (16.95±1.11 seconds) and Wycope VL (20.29±2.81 seconds) with P=0.000.
Conclusion . DL was faster compared to VL in speed of intubation while C-MAC VL and Wycope VL was faster in viewing the vocal folds and glottis compared to DL.</p
... With the introduction of the video laryngoscopes, improved view of the glottis is obtained as compared with conventional direct laryngoscopy and is now the first choice or default device of some anaesthetists. 1 Despite various innovations and numerous developments in the airway devices, the Macintosh curved-blade laryngoscope (MBL) remains the most frequently used and the "gold standard" device for orotracheal intubation against which various airway devices are evaluated. 2 Introduction of video laryngoscopes in an anaesthesiologist's armamentarium has proven to be an excellent airway management device, especially for securing airway in patients with ADI. ...
Background
Various types of laryngoscopes have been invented to ameliorate the laryngoscopic view of the glottis, in normal and difficult airway, which helps anaesthesiologists to secure the airway during anaesthesia. In this prospective study, we aimed to compare the efficacy of the Airtraq video laryngoscope (AVL) and the Macintosh curved-blade laryngoscope (MBL), by using a common clinical assessment tool in patients with modified Mallampati class III and IV.
Methods
A total of 60 patients [group A (AVL) and group M (MBL)] with modified Mallampati class III and IV listed for general anaesthesia were included. Each patient was intubated with either of the laryngoscope based on the group allotted. Time taken for tracheal intubation, grade of visualisation of glottis and need for manoeuvres to optimise the glottic view were compared.
Results
The degree of the glottic view during successful intubation attempt was easily appreciated in group A (p < 0.0001). Difference in the requirement of manoeuvres for optimising the laryngeal view/assisting in intubation as assessed by manoeuvre score was easily appreciated in group A (p < 0.010). Rise in heart rate and mean arterial pressure 1 and 2 min after intubation was more in group M than in group A (p < 0.0001). No event of any airway trauma, as evidenced by visible trauma to lips or oral mucosa or blood on laryngoscope, was observed with either of the laryngoscope.
Conclusion
The novel AVL provides better intubation conditions with greater ease of intubation, better glottic view and lesser haemodynamic alterations during laryngoscopy than MBL.
... The advantages of using a VL with an acute angulation of 60 degrees in difficult airways are obvious; however, the feasibility of using an acute-angled VL during the first attempt of intubation in normal airways has been questioned [9]. The hyperacute-angle blade may result in impingement of the tube tip against the cricoid ring due to the acute angle of the tube path [10]; moreover, the gap between the camera and tube-insertion angle requires intricate eye coordination, which could negatively affect tube guidance, increase in intubation time [11], and cause intubation failure [9]. ...
The curvature of a videolaryngoscope blade has been diversified from the standard macintosh-type to the hyperacute-angle-type, resulting in different performances. We aimed to determine the intubation success rate and identify predictors of difficult intubation when using an intermediate-angled videolaryngoscope in the first attempt of intubation under routine anaesthesia settings. We enrolled 808 patients between 19 and 79 years of age, scheduled for elective surgeries under general anaesthesia with orotracheal intubation from July 2017 to November 2018; patients who were candidates for awake intubation were excluded. We obtained patient demographic data and performed airway evaluation before induction of anaesthesia for elective surgeries. We used the UEScope for tracheal intubation with a hockey stick-shaped malleable stylet. The intubation time was defined as the total duration from the entry of the blade into the oropharynx to the detection of first end-tidal carbon dioxide capnogram; this duration was recorded along with the number of intubation attempts. Difficult intubation was defined as either > 60 s duration for tracheal intubation, or > 1 intubation attempt. The use of the UEScope demonstrated a 99.4% success rate for intubation; however, increased difficulties were observed in patients who were male, obese, had a short thyromental distance, limited mouth opening, and high upper-lip-bite test class. Despite the high intubation success rate using an intermediate-angled videolaryngoscope, we recommend preparing backup plans, considering the increased difficulty in patients with certain preoperative features.Clinical trial number and registry URL: Clinical Trials.gov Identifier: NCT03215823
(Date of registration: 12 July)
... Preoperative assessment of the patient's airway facilitates the anesthesiologists to predict the ease of visualizing the glottis and to perform intubation easily. Various studies have shown the incidence of difficult intubation ranging between 9% and 16% [1,2] while the incidence of difficult intubation in the intensive care unit (ICU) or Emergency Medicine Department is probably as high as 20% [3]. Though there are several conventional clinical airway assessment parameters such as the modified Mallampati classification [4,5], hyomental distance, thyromental distance, neck movements, inter incisor gap, BMI, and ability to flex and extend the cervical spine, neck circumference, upper lip bite test, etc. which are usually used to predict a difficult airway preoperatively [6], the diagnostic accuracy of these predictors in predicting difficult intubation is low during pre-anesthetic airway assessment [7] and unexpected difficult intubations continue to occur. ...
Background and aims
Management of difficult airway can be associated with serious morbidity and mortality and it is a basic and serious concern for anesthesiologists. The preoperative airway assessment is done by using conventional clinical predictors. The present study was conducted to find the correlation of various new clinical predictors with the Cormack-Lehane (CL) grade at the laryngoscopic view in patients undergoing general anesthesia with endotracheal intubation.
Settings and design
The prospective, comparative, observational, double-blind study was carried at Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow.
Materials and methods
The study was conducted in 150 patients undergoing elective surgery under general anaesthesia. The primary outcome was the measurement of clinical airway assessment preoperatively based on certain parameters (inter incisor gap (IIG), modified Mallampati grading (MPG), neck circumference/thyromental distance (NC/TMD), ratio of height to thyromental distance (RHTMD)). The secondary outcome was the correlation of clinical airway assessment with CL grading to predict difficult intubation. The sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV) of the parameters were assessed.
Statistical analysis
The association between different predictors and difficult laryngoscopy was evaluated using binary univariate logistic regression and multivariate logistic regression and the significant clinical predictors were assessed by using Pearson’s correlation. A p-value of < 0.05 was considered significant.
Results
The incidence of difficult intubation in this study was 13.3%. Among the clinical predictors, the Mallampati grading has the maximum receiver operating characteristic (ROC) and area under the curve (AUC) with 86.7 % sensitivity to predict difficult laryngoscopy followed by NC/TMD and body mass index.
Conclusion
Modified Mallampati grading still holds its significant value among new predictors in the assessment of difficult laryngoscopy.
... We choose MAC design VL (C-MAC and McGrath) to compare intubation time and comfort of use as these both are readily available in our setup and their proposed ease of use as compared to anatomically designed channeled or non channeled VLs. [12,13] In the current pandemic situation, training and familiarity with the use of VLs is the need of the hour. A paradigm shift in practice with universal VL for intubation in both COVID and non-COVID scenarios is being suggested. ...
Introduction: Intubation in COVID patients is challenging. Various guidelines suggest the use of video-laryngoscope (VL) as the first device to aid intubation in a COVID patient. The best VL to facilitate intubation in such a setting especially by novices is not ascertained. We compared intubation characteristics by two VL's (McGrath-MAC and C-MAC) for intubation in a COVID simulated mannequin by novices.
Methodology: This prospective randomized manikin-based crossover study was done in thirty medical professionals with no previous experience of intubation with VL. All participants were trained on Laerdel airway management trainer and were allowed 5 practice sessions with each scope with an intubation box while wearing face protective personal protective equipment (PPE). Participants were randomized into two groups of 15 each, one group performed the intubation first with McGrath and the other with C-MAC before crossing over.
Results: The mean (S. D.) time to intubation was similar with both McGrath-VL and CMAC VL [31.33 (14.72) s vs 26.47 (8.5) s, P = (p-0.063)]. POGO score [mean (S. D.)] was better with CMAC [81.33 (16.24) vs 60.33 (14.73), p-0.00. The majority of the users preferred C-MAC VL for intubation (93.33%). The incidence of failed intubation and multiple attempts at intubating were similar with the two scopes.
Conclusion: The time to intubation was similar with both VL's but the majority of novices preferred CMAC probably due to a bigger screen that helped them to have a better view of glottis in the COVID simulated mannequin.
... Clinicians are advised to look into the mouth during the introduction of video laryngoscope, then obtain the desired Data is presented as mean±SD or number (%) of patients view on screen and look in for initial introduction of the tube [14] A videolaryngoscope has lesser flange height of 1.6 cm as compared to 2.5 cm in case of a Macintosh laryngoscope. A reduced space as well as the wrong technique of looking only at the screen resulted in the two instances of cuff tears. ...
Background and Aims: Double lumen tube (DLT) insertion for isolation of lung during thoracic surgery is challenging and is associated with considerable airway trauma. The advent of video laryngoscopy has revolutionized the management of difficult airway. Use of video laryngoscopy may reduce the time to intubate for DLTs even in patients with normal airway.
Material and Methods: A total of 87 ASA 1–3 adults, scheduled to undergo elective thoracotomy, requiring a DLT were randomly allocated to videolaryngoscope (CMAC) arm or Macintosh laryngoscope arm. It was on open label study, and only the patient was blinded. The primary objective of this study was to compare the mean time taken for DLT intubation with CMAC (Mac 3) and Macintosh laryngoscope blade and the secondary objectives included the hemodynamic response to intubation, the level of difficulty using the intubation difficulty scale (IDS), and complications associated with intubation. Data was analysed using the statistical software SPSS (version 18.0).
Results: The time taken for intubation was not significantly different (42.8 ± 14.8 s for CMAC and 42.5 ± 11.5 s for Macintosh laryngoscope P -0.908). The CMAC video laryngoscope was associated with an improved laryngoscopy grade (Grade I in 81.8% with CMAC and in 46.5% with Macintosh), less pressure applied on the tongue, and less external laryngeal pressure required. Hemodynamic responses to intubation were similar in both groups.
Conclusion: Macintosh blade is as good as CMAC (mac 3) blade to facilitate DLT intubation in adult patients with no anticipated airway difficulty, however CMAC was superior as it offers better laryngoscopic view, needed less force, and fewer external laryngeal manipulations.
... Our approach was developed using the techniques with which our team were most experienced and comfortable. Modifications of the approach could involve the use of video laryngoscopy to observe the withdrawal of the tracheal tube, rather than digital palpation [18,19]. However, we feel that direct laryngoscopy, which exposes the operator to the airway at minimal distance is not appropriate [6]. ...
Background
COVID-19 is a global pandemic with many patients requiring prolonged mechanical ventilation. COVID-19 is associated with laryngeal oedema and a high rate of reintubation and difficult airway. Tracheostomy insertion is an aerosol generating procedure, so we strived to make our novel technique safe for operator and patient.
Aim
To share our experience of a novel percutaneous tracheostomy technique, based on a case series of 18 patients with COVID-19 pneumonitis.
Method
Our novel percutaneous tracheostomy technique is a landmark-based approach without bronchoscopic confirmation of the correct needle placement. Blunt dissection using tracheal dilators onto the tracheal rings facilitates first pass needle insertion into the trachea. The tracheal tube is retracted into the supraglottic airway, the cuff overinflated, and a wet throat pack inserted to reduce aerosolisation.
Results
From March 2020 to May 2020, 38 patients with suspected or confirmed COVID-19 presented to Royal Bolton Hospital requiring invasive ventilation. 18 patients underwent percutaneous tracheostomy. 6 patients have been decannulated, 12 patients died. Mean time from intubation to tracheostomy was 6.1 days and from tracheostomy to decannulation 20.6 days. No operator developed COVID-19 symptoms.
Conclusions
Despite the low numbers our novel technique appears to be safe, but confirmation requires a larger controlled trial. As an institution we have avoided difficulties with reintubation and reduced our drug usage.
