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PubMed1996

Effectiveness of a manually controlled infusion scheme of propofol and alfentanil mixture for endotracheal intubation in hypertensive patients: in comparison with thiamylal and nifedipine plus thiamylal.

BACKGROUND: Bolus administration of propofol for induction causes hypotension, especially in elderly hypertensive patient. Carefully titrated infusion of propofol minimizes adverse effects, such as hypotension, and permits a rapid recovery of its central effects. The objective of this study was to investigate the effect of a manually controlled infusion scheme of propofol and alfentanil mixture on hemodynamic stability during induction and endotracheal intubation for hypertensive patient. At the same time, the effectiveness of this scheme was compared with two other induction regimens (thiamylal or nifedipine plus thiamylal). METHODS: Sixty hypertensive patients undergoing orthopedic surgery were randomized into 3 groups (n = 20 per each group), None of the patients received premedication. Anesthesia was induced in group 1 (G1) with alfentanil 10 micrograms/kg. 30 s later, manual infusion of a mixture of propofol (10-12 mg/kg/h) and alfentanil (25 micrograms/kg/h) was performed for 2 min, followed by atracurium (5 mg) and propofol (1-1.5 mg/kg) as a bolus induction dose over 20 s, and then Suxamethonium (1.5 mg/kg) at 30-40 s later. Intubation was done while giving a continuous infusion of propofol and alfentanil. After intubation, the infusion rate was adjusted according to the blood pressure (BP) variation. Group 2 patients (G2) were induced with fentanyl (2 micrograms/kg), thiamylal (4-5 mg/kg), atracurium (5 mg) and succinylcholine (1.5 mg/kg). Induction of anesthesia in group 3 patients (G3) was the same as for G2, with additional sublingual nifedipine (1/2 capsule) 10 min prior to induction. Extra bolus dose of propofol (20 mg) or thiamylal (20 mg) was given at every 15 s if the systolic BP was still higher than 160 mmHg after induction by the above 3 regimens. The radial arterial pressure and electrocardiogram were continuously recorded for evaluation of hemodynamic changes. RESULTS: Post-intubation peak mean arterial pressure (MAP) in G1 and G3 were below to awake baseline values, while MAP of G2 was significantly higher than over awake baseline level (p < 0.001). The lowest MAP of G3 at post-intubation period before surgical stimulation were significantly lower than those of G1 and G2 (p < 0.001). Peak tachycardiac response to intubation in G2 was significantly higher than G1 (p < 0.05). After intubation, the peak rate pressure product were significantly higher in G2 compared with that in G1 (p < 0.05) and G3 (p < 0.001). CONCLUSIONS: The proposed manual infusion scheme of propofol and alfentanil mixture performed during induction and intubation attenuated the subsequent peak pressor response to incubation and reduced the hypotensive effect, in comparison to thiamylal or thiamylal plus nifedipine treatment, during post-intubation period. The same infusion scheme also attenuated the tachycardiac response to intubation.

Aged↗
PubMed1997

[Intubation of afferent lacrimal ducts--a review of techniques].

The authors present a review of various techniques of long-term intubation of efferent lacrimal pathways by a silicone fibre. They use an original way of intubation and intubate the insertion probes of the intubation set from the lower nasal outlet by means of a titanium loop under direct optic control by means of an endoscope. The use of the endoscope makes it possible to reduce the number of complications and iatrogenic damage of the mucosa and it enhances the effectiveness of the procedure. The authors prefer the use of special intubations sets; for young children intubation sets made from soft metal are preferable. At present all their demands are met by the intubation set they developed in collaboration with the Technical University, Prague. During the period between April 1994 and August 1996 the authors used the described technique for bicanalicular intubation of the efferent lacrimal pathways in 127 children and in adult patients 6x. In 86 instances they used an intubation set of Geuder Co., 44 times their own intubation set.

Adult↗
PubMed1998

[Circulatory changes at the time of anesthetic induction and endotracheal intubation--comparison of thiamylal induction group and propofol induction group].

We examined the circulatory changes after intravenous thiamylal with additional injection of thiamylal 1 minute before intubation and after propofol at the time of anesthetic induction and endotracheal intubation. Sixty ASA I or II patients were studied after the institutional and informed consents. We compared the following three groups. Group I (n = 20): Anesthesia was induced with thiamylal 5 mg.kg-1 and intubation with the aid of vecuronium 0.1 mg.kg-1. Group II (n = 20): Anesthesia was induced with thiamylal 3 mg.kg-1 and vecuronium 0.1 mg.kg-1. One minute before the intubation, the patients received additional thiamylal 4 mg.kg-1. Group III (n = 20): Anesthesia was induced with propofol 2.5 mg.kg-1 and intubation was performed with the aid of vecuronium 0.1 mg.kg-1. We examined the systolic, diastolic and mean blood pressures, heart rate, and rate pressure product (RPP) in the three groups. The examinations were performed before and after induction, soon after intubation, and every one minute after intubation for 5 minutes. After the endotracheal intubation, the systolic blood pressure and heart rate increased in Group I. But the systolic and diastolic pressures were significantly more stable in Group II and Group III. The change of the RPP was slight and most stable in Group II compared with the other two groups. We conclude that additional injection of thiamylal 4 mg.kg-1 following induction of anesthesia with thyamylal 3 mg.kg-1 1 minute before endotracheal intubation is an effective method for minimizing the increase in blood pressure and circulatory changes at the time of rapid induction of anesthesia and endotracheal intubation.

Adjuvants, Anesthesia↗
PubMed1998

A survey of sedation protocols used for emergency endotracheal intubation in poisoned patients in the French prehospital medical system.

The purpose of this study was to evaluate prehospital sedation protocols used by several French mobile intensive care units for difficult intubations in poisoned patients. This prospective, descriptive study was performed within the toxicological intensive care unit in a university hospital. Consecutive poisoned patients intubated during their airway management by prehospital medical teams were included. Intubating physicians completed a one-page checklist concerning the circumstances of endotracheal intubation. Intubation difficulty was significantly related to the nature of sedation protocols. The use of etomidate alone as an intubation sedative agent was associated with significantly poorer intubating conditions (47.2% difficult) than other sedative agents or neuromuscular blockade). Neuromuscular blockade with sedation in our series was associated with the lowest incidence of difficult intubations in poisoned patients. Sedation alone for intubation appears to be inadequate to achieve good intubating conditions in a significant proportion of patients.

Adult↗
PubMed2005

[Impact of Cormack and Lehane's grade on Intubating Laryngeal Mask Airway Fastrach using: a study in gynaecological surgery].

OBJECTIVE: To evaluate the impact of Cormack and Lehane grade on the Intubating Laryngeal Mask Airway (LMA-Fastrach) using in women. STUDY DESIGN: Open prospective study. PATIENTS: The study included 115 scheduled gynaecologic surgery women. METHODS: An LMA-Fastrach was systematically performed in patients with a Cormack's grade > or =3 or when Arne's score was > or =7 whatever the Cormack. After induction of anaesthesia and neuromuscular blockade, Cormack's grade was assessed and LMA-Fastrach was inserted. Proper insertion was confirmed by the easiness of assisted ventilation and the normal aspect of the capnographic curve. Intubation through the LMA-Fastrach was carried out with the specific kit's endotracheal tube. More than two attempts were considered as a failure of the technique and an alternative method was performed. The following parameters were noted: age, weight, height, clinical predictors for difficult intubation (Arne et al.'s score), number of LMA-Fastrach insertion, ventilation efficiency through LMA-Fastrach, successful intubation with LMA-Fastrach and oesophageal intubation. RESULTS: Ventilation through the LMA-Fastrach was efficient in 97%. The success rate of intubation was 94.8% (86% on the first attempt). The success rate of ventilation and intubation were not statistically different according to the different Cormack's grades. The obesity (BMI>30) did not change the success rate of ventilation and intubation through the LMA-Fastrach. CONCLUSION: In women with either predicted or unpredicted difficult intubation, the success rates of ventilation and intubation through the LMA-Fastrach don't seem to be influenced by Cormack grade and obesity.

Adult↗
PubMedDate not supplied

[Esophageal intubation for palliative treatment in advanced carcinoma of the esophagus and cardia].

This is a report of 121 cases of advanced esophageal and cardia cancer managed by endoscopic and surgical esophageal intubation. They were submitted to surgical intubation 69 (53%) patients, and 52 (47%) to endoscopic intubation. There were 32.5% of technical complications in endoscopic intubation and 26.5% in surgical intubation. Perfuration was more frequent (11.5%) in endoscopic intubation than surgical group. Mortality rate was 17.3% for endoscopic and 5.8% for surgical intubation. Perfuration was the main cause of death in endoscopic intubation. Survival rate was 3.5 months for endoscopic and 4.7 months for surgical intubation. The majority of patients died of cancer evolution--caquexia (55.5%), carcinomatosis (4.5%) and brain methastasis (1.1%). The results of endoscopic and surgical intubation in this group of patients recommend its use in patients with advanced esophageal and cardic cancer.

Adenocarcinoma↗
PubMed2001

Capnography alone is imperfect for endotracheal tube placement confirmation during emergency intubation.

This analysis primarily sought to determine the effectiveness of end-tidal capnography for tube placement confirmation during emergency airway management. Secondary objectives were validation of the rate of unanticipated esophageal placement during emergency intubation and quantification of the portion of intubations performed in patients with cardiac arrest where capnography is not recommended. The study was performed in two phases. For the primary objective, a meta-analysis was performed on all experimental capnography trials enrolling emergency populations. For the secondary objectives, inadvertent esophageal intubation and cardiac arrest rates were calculated from a large prospective multicenter observational study of emergency intubation cases. Data analysis included calculation of descriptive statistics, sensitivity, specificity, and confidence intervals (CI). Based on 2,192 intubations, a meta-analysis of previous capnography trials resulted in an aggregate sensitivity of 93% (95% CI 92-94%) and an aggregate specificity of 97% (CI 93-99%) for emergency tube placement confirmation. Thus, for emergency capnography use, the false-negative failure rate (tube in trachea but capnography reports esophagus) was 7% and the false-positive rate (tube in esophagus but capnography reports trachea) was 3%. This translates to potential harm for one patient in every 10 treated with capnographic confirmation alone (number needed to harm: 14 for false-negative, 33 for false-positive, and 10 for both). A further literature review demonstrated no sole method of tube placement confirmation is completely foolproof. Of 4,602 consecutive intubations reported to the National Emergency Airway Registry, 4% of emergency intubation attempts resulted in accidental esophageal intubation, and 10% occurred in nontraumatic cardiac arrest patients. During tracheal intubation of critically ill patients, it is concluded that the rate of accidental esophageal tube placement warrants continued improvement in emergency airway techniques. Misidentification of esophageal placement in the emergency setting may occur with capnography. Multiple methods of tube placement confirmation are superior to any single method because no single method has perfect accuracy.

Capnography↗
PubMed1997

Endotracheal intubation in the field improves survival in patients with severe head injury. Trauma Research and Education Foundation of San Diego.

OBJECTIVE: To measure the effect of prehospital endotracheal intubation on outcome in patients with severe head injury and the percentage of these patients intubated in the field under existing protocol. DESIGN: Retrospective case-control study. SETTING: Countywide urban trauma system. PATIENTS: Trauma patients with blunt injury and scene Glasgow Coma Score of 8 or less, transported by ground ambulance with advanced life support capabilities from January 1, 1991, to December 31, 1995. Severe head injury was defined as head or neck Abbreviated Injury Scale score of 4 or greater. Isolated severe head injury was defined as head or neck Abbreviated Injury Scale score of 4 or greater with no other Abbreviated Injury Scale component greater than 3. One thousand ninety-two patients met initial criteria; of these, 671 had severe head injury, and 351 had isolated severe head injury. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Mortality and functional status sufficient for discharge to home. RESULTS: Field intubation was associated with significant decreases in mortality from 36% to 26% in the full study group, from 57% to 36% in patients with severe head injury, and from 50% to 23% in patients with isolated severe head injury. Rate of discharge to home was unaffected by field intubation. Between 50% and 60% of study patients were intubated under current paramedic protocol, compared with intubation rates of 85% to 92% for similar patients transported by aeromedical teams operating under expanded indications for intubation. CONCLUSIONS: Prehospital endotracheal intubation was associated with improved survival in patients with blunt injury and scene Glasgow Coma Score of 8 or less, especially those with severe head injury by anatomic criteria. Broadening indications for intubation by paramedical personnel has great potential to improve outcome in patients with severe head injury.

Adult↗
PubMed1995

The use of capnography for recognition of esophageal intubation in the neonatal intensive care unit.

Failure to recognize esophageal intubation can result in severe hypoxia and permanent neurologic injury. Capnography is a standard monitoring modality in the operating room but has not been utilized fully in other environments. We used capnography at the time of endotracheal intubation in the neonatal intensive care unit (NICU) to determine whether capnography could more quickly and accurately identify endotracheal tube position than other clinical indicators of endotracheal tube position. One hundred intubation episodes were studied in 55 neonates. Capnograms were obtained 15 and 120 sec following tube placement. Intubating personnel were blinded to the capnographic data and determined endotracheal tube location (trachea vs. esophagus) by clinical criteria only. The sensitivity and specificity of capnography and clinical examination for identification of tube position were analyzed, and the time required for establishing by clinical confirmation whether the tube was in the trachea or not was compared to that required for capnography. Forty of 100 intubation attempts resulted in esophageal intubation. Capnography correctly identified these errant tube placements in 39 of 40 instances and did so in 1.6 sec (SD +/- 2.4). Capnography failed to identify successful endotracheal intubation on only one occasion. Clinical indicators of tube position required 97.1 sec (SD +/- 92.6) to identify an esophageal intubation and failed to identify successful endotracheal intubation in 5 of 60 cases. We conclude that capnography is a valuable adjunct to clinical examination to demonstrate whether an endotracheal tube is placed correctly in the trachea of neonates in the NICU.

Blood Gas Monitoring, Transcutaneous↗
PubMed1995

Evaluation of the Augustine Guide for difficult tracheal intubation.

Successful tracheal intubation with Augustine Guide (Augustine Medical, Inc., Eden Prairie, MN) in patients with normal airways has recently been described. There are no studies describing Augustine Guide (AG) use in patients with difficult airways. Accordingly, we studied AG intubation in a population of patients with expected difficult airways due to cervical spine pathology, limited mouth opening, obesity, facial trauma or deformity due to previous operation or radiation and in patients with unexpectedly difficult airways. A total of 44 patients were studied. The AG was used as a primary intubating tool in patients with known difficult airways (n = 36) and as a secondary intubating tool in patients with unexpected inability to intubate using conventional direct laryngoscopy (n = 8). Airway difficulty was predicted by history and physical examination. Intubations were performed under general anaesthesia in 40 of the 44 patients studied. In four patients with predictably difficult airways, topical anaesthesia and sedation were used. Backup methods to achieve intubation were available. Thirty-two of the 36 with known or suspected difficult airways were classified as Mallampati Class III or IV. In the remaining eight patients the preoperative examination suggested an easy airway; however, after induction of general anaesthesia, their laryngeal inlet could not be seen using direct laryngoscopy. Using the AG, all were intubated successfully (36/44 at the first attempt, in 8/44 repositioning of the AG to allow successful laryngeal entry of the stylet was necessary). There were no failures or complications secondary to AG use. This study shows that the AG is a useful device for oral tracheal intubation in patients with known or unexpectedly difficult airways.

Adult↗
PubMedDate not supplied

Airway management after failure to intubate by direct laryngoscopy: outcomes in a large teaching hospital.

PURPOSE: The purpose of this single-centre database review was to establish the incidence of failure to intubate by direct laryngoscopy, to measure morbidity and mortality associated with this event, and to examine the use and efficacy of alternative airway devices. METHODS: Difficult intubation via direct laryngoscopy at Mayo Clinic Rochester is recorded in an electronic database using a functional classification: 0 = no difficulty; 1 = mild to moderate difficulty; and 2 = severe difficulty often requiring a change in intubation technique. Using this database, the total number of intubations was determined for a selected review period and the incidence of failure to intubate by direct laryngoscopy was established. Abstraction of chart data allowed for determination of associated morbidity and mortality, success of alternative airway devices, and case cancellation rate. RESULTS: During the period from August 1, 2001 through December 31, 2002, 37,482 patients underwent general anesthesia with attempted direct laryngoscopy. One hundred sixty-one patients (0.43%) could not be intubated by direct laryngoscopy alone. Morbidity associated with difficult intubation included soft tissue/dental damage (n = 8), intraoperative cardiac arrest (n = 1), and possible aspiration (n = 1). Three patients required intensive care unit admission. There was no associated mortality. The most commonly used alternative airway device was the flexible fibreoptic scope. Five case cancellations resulted from failure to intubate with alternative devices. CONCLUSION: The rate of unexpected failure to intubate by direct laryngoscopy is essentially unchanged from earlier studies. While morbidity was low, continued education and early use of alternative difficult airway devices may further limit complications associated with this event.

Anesthesia, General↗
PubMed2005

Propofol is superior to thiopental for intubation without muscle relaxants.

PURPOSE: To compare intubating conditions and cardiovascular changes following induction of anesthesia and tracheal intubation in patients receiving either lidocaine-remifentanil-propofol or lidocaine-remifentanil-thiopental prior to induction. METHODS: In a randomized, double-blind study 76 healthy adult patients were assigned to one of two groups: lidocaine 1.5 mg.kg(-1), remifentanil 2 mug.kg(-1) and propofol 2 mg.kg(-1) (Group P) or lidocaine 1.5 mg.kg(-1), remifentanil 2 mug.kg(-1) and thiopental 5 mg.kg(-1) (Group T). Ninety seconds after the administration of the hypnotic agent, laryngoscopy and tracheal intubation were attempted. Intubating conditions were assessed as excellent, good or poor on the basis of ease of ventilation, jaw relaxation, position of the vocal cords, and patient's response to intubation and slow inflation of the tracheal cuff. The mean arterial pressure (MAP) and heart rate (HR) were measured 45 sec after hypnotic agent administration, immediately after tracheal intubation, two and five minutes after intubation. RESULTS: Excellent intubating conditions were obtained in 84% of Group P patients and 50% of Group T patients (P < 0.05). The percentage decrease from baseline MAP was significantly higher in Group P than in Group T postinduction (27.4% +/- 11.6 vs 21.8% +/- 10.0) and immediately postintubation (19.0% +/- 16.7 vs 11.2% +/- 14.9). The percentage change from baseline HR was significantly higher in Group P than in Group T postinduction (13.8% +/- 9.7 vs 0.5% +/- 12.4), immediately postintubation (8.7% +/- 13.7 vs 2.1% +/- 13.1), and two minutes postintubation (7.04% +/- 14.3 vs 3.5% +/- 14.3). CONCLUSION: Lidocaine-remifentanil-propofol is superior to lidocaine-remifentanil-thiopental for tracheal intubation without muscle relaxants. However, it induces more hypotension and bradycardia.

Adolescent↗
PubMed2003

Propofol - not thiopental or etomidate - with remifentanil provides adequate intubating conditions in the absence of neuromuscular blockade.

PURPOSE: Administration of remifentanil followed by propofol provides adequate conditions for tracheal intubation without muscle relaxants. Other hypnotic drugs have not been thoroughly investigated in this regard. Intubating conditions with remifentanil followed by propofol, thiopentone or etomidate are compared in this study. METHODS: In a randomized, double-blind study 45 healthy males were assigned to one of three groups (n = 15). After iv atropine, remifentanil 3 microg x kg(-1) were injected over 90 sec followed by propofol 2 mg x kg(-1) (Group I), thiopentone 6 mg x kg(-1) (Group II) or etomidate 0.3 mg x kg(-1) (Group III). Ninety seconds after the administration of the hypnotic agent, laryngoscopy and intubation were attempted. Intubating conditions were assessed as excellent, good or poor on the basis of ease of ventilation, jaw relaxation, position of the vocal cords, and patient response to intubation and slow inflation of the endotracheal tube cuff. RESULTS: One patient in Group I, three patients in Group II and five patients in Group III could not be intubated on the first attempt. Clinically acceptable intubating conditions were observed in 93.3%, 66.7%, 40.0% of patients in Groups I, II and III, respectively. Overall conditions at intubation were significantly (P < 0.05) better, and the frequency of excellent conditions was significantly (P < 0.05) higher in the propofol group compared with the thiopentone and etomidate groups. No patient was treated for hypotension or bradycardia. CONCLUSION: Propofol 2 mg x kg(-1) was superior to thiopentone 6 mg x kg(-1) and etomidate 0.3 mg x kg(-1) for tracheal intubation when combined with remifentanil 3 microg x kg(-1) and no muscle relaxant.

Adolescent↗
PubMed2003

Muscle relaxation and increasing doses of propofol improve intubating conditions.

PURPOSE: Muscle relaxants and anesthetics are usually associated during intubation. However, their relative role to facilitate the process is not clearly defined. This study was designed to determine, during intubation: i). the relative role of anesthetics and atracurium-induced neuromuscular block and; ii). the effect of different doses of propofol in the presence of complete muscle block. METHODS: Patients were randomized to four groups and received fentanyl and a standardized anesthetic procedure. Patients from groups high (H; n = 45), medium (M; n = 48) and low (L; n = 47) received 2.5 mg x kg(-1), 2.0 mg x kg(-1), and 1.5 mg x kg(-1) of propofol respectively. Atracurium (0.5 mg x kg(-1)) was then injected and tracheal intubation performed once complete block was achieved at the orbicularis oculi. Patients from group without atracurium (WA; n = 20) received propofol as in group H. Intubation was performed at the expected onset time of action of atracurium. RESULTS: Using the same dose of propofol, the incidence of good or excellent intubating conditions was 35% without atracurium and 95% with atracurium (P < 0.0001). In patients receiving atracurium, clinically acceptable intubating conditions were more frequently achieved in groups receiving the highest propofol doses (group H or M vs group L; P < 0.03). CONCLUSION: Our study confirms the interaction between anesthesia and muscle relaxation to produce adequate intubating conditions. In the conditions described, intubating conditions were more dependent on atracurium-induced neuromuscular blockade than on anesthetics, but both atracurium and propofol improved intubating conditions.

Adolescent↗
PubMed2000

Predicting difficult intubation: a multivariable analysis.

PURPOSE: To develop a clinically useful and valid model for predicting difficult laryngoscopic tracheal intubation in patients with seemingly normal airways by adhering to the principles of multivariable model development. METHODS: This was an observational study performed at a tertiary-care teaching hospital. Preoperatively, 444 randomly selected patients requiring tracheal intubation for elective surgery were assessed. In addition, 27 patients in whom tracheal intubation was difficult, but were not assessed preoperatively, were assessed postoperatively. One assessor, blinded to the intubation information, collected the predictor variables. A reliable definition for difficult intubation was used and all attempts were made to eliminate sources of bias. Multivariable modeling was performed using logistic regression and the model was validated using the bootstrapping technique. RESULTS: Of the 461 patients included in the analysis, 38 were classified as difficult to intubate. Multivariable analysis identified three airway tests that were highly significant for predicting difficult tracheal intubation. These were: 1) "mouth opening", 2) "chin protrusion", and 3) "atlanto-occipital extension". Using these tests, a validated, highly reliable and predictive model is produced to determine the probability of difficult intubation for patients. At a selected probability cut-off value, the model is 86.8% sensitive and 96.0% specific. CONCLUSION: A simple and accurate multivariable model, consisting of three airway tests, is produced for predicting difficult laryngoscopic tracheal intubation. Additional studies will be required to determine the accuracy and feasibility of this model when applied to a large sample of new patients by multiple anesthesiologists.

Adult↗
PubMed2000

The intubating LMA: a comparison of insertion techniques with conventional tracheal tubes.

PURPOSE: To compare the performance of the intubating laryngeal mask airway (ILMA) in assisting blind tracheal intubation with conventional tracheal tubes of different curvatures and the frequency of possible associated complications. METHODS: After informed consent, 240 ASA I-II adults undergoing elective surgery participated in a randomized, single blind clinical trial to receive blind trachea intubation via ILMA with a conventional tracheal tube curved with normal (Normal group) or reversed (Reverse group) direction. More than three attempts at intubation was regarded as failure. The lowest oxygen saturation during intubation was recorded and postintubation sore throat and hoarseness were evaluated with verbal analog scales. RESULTS: The overall success rates of intubation with Normal and Reverse groups were not different (96.7% and 94.2% respectively). Successful intubation at the first attempt was higher in the Reverse group than in the Normal group (86.7% vs 75.0%, P=0.033). The incidence of sore throat was higher in the Normal group than in the Reverse group (19.2% vs 9.2% respectively, P =0.042). CONCLUSIONS: Blind trachea intubation via an ILMA with the conventional curved tracheal tube is feasible and highly successful. Reverse curve direction is preferable at the first attempt of intubation for its higher success rate and lower incidence of complications.

Adolescent↗
PubMed2003

Straight blades improve visualization of the larynx while curved blades increase ease of intubation: a comparison of the Macintosh, Miller, McCoy, Belscope and Lee-Fiberview blades.

PURPOSE: To compare the Macintosh (M), McCoy (MC), Miller (MIL), Belscope (BP) and Lee-Fiberview (LF) laryngoscopes with respect to the grade of laryngeal visualization and the difficulty of intubation. METHODS: We included 500 patients scheduled to undergo elective surgery and who required tracheal intubation. Patients were randomly assigned to five groups of 100 patients each. Anesthesia was induced intravenously using 1-3 mg.kg(-1) of propofol, fentanyl 1.5 microg.kg(-1) and atracurium 0.5 mg.kg(-1) or suxamethonium 1 mg.kg(-1). The laryngeal view was classified according to Cormack and Lehane. The degree of difficulty with intubation was rated as: Grade 1, intubation easy; Grade 2, intubation requiring an increased anterior lifting force and assistance to pull the right corner of the mouth upwards to increase space; Grade 3, intubation requiring multiple attempts and a curved stylet; Grade 4, failure to intubate with the assigned laryngoscope. Data were examined using analysis of variance, chi(2) or Fisher test, Student's t test and odds ratio. P < 0.05 was considered statistically significant. RESULTS: Laryngoscopic views obtained with the BP and MIL laryngoscopes were similar, and better than with the other types of laryngoscopes (P < 0.001). The levering tip of the MC blade (P = 0.02) and the fibreoptic device of the LF (P < 0.001) significantly improved the laryngoscopic view. Regarding the degree of difficulty with intubation, the best results were obtained with the MC and M blades (P < 0.001). CONCLUSION: Laryngoscopy was better with straight blades but curved blades provided better intubating conditions.

Anesthesia↗
PubMed2007

Effect of stylet angulation and endotracheal tube camber on time to intubation with the GlideScope.

PURPOSE: The GlideScope videolaryngoscope usually provides excellent glottic visualization, but directing an endotracheal tube (ETT) through the vocal cords is sometimes difficult. The goal of the study was to determine which of two ETT angles (60 degrees vs 90 degrees ) and cambers (forward vs reverse) was better, as determined by time to intubation (TTI). METHODS: Two hundred patients requiring orotracheal intubation for elective surgery were randomly allocated to one of four groups: A) 90 degrees angle, forward camber; B) 90 degrees angle, reverse camber; C) 60 degrees angle, forward camber; D) 60 degrees angle, reverse camber. Time to intubation was assessed by a blinded observer. Operators were blinded until the point of intubation. A visual analogue scale (VAS) assessed the ease of intubation. The number of intubation attempts, number of failures, glottic grades, and use of external laryngeal manipulation were recorded. RESULTS: The angle of the ETT had an impact on TTI but camber did not. The 90 degrees angle demonstrated a 13% faster TTI than the 60 degrees angle (47.1 +/- 21.2 sec vs 54.4 +/- 28.2 sec, P=0.042), and it resulted in easier intubation (VAS 16.4 +/- 14.2 mm vs 27.3 +/- 23.5 mm, P=0.0001). The overall incidence of a grade 1 or 2 Cormack-Lehane glottic view was 99%. CONCLUSIONS: In a heterogeneous group of operators and patients intubated with the GlideScope, a 90 degrees ETT angle provided the best result and should be the initial configuration. The camber of the ETT does not affect the time to intubation.

Adult↗