scholarly journals Is there an optimal place to hold the endotracheal tube during direct laryngoscopy for patients undergoing surgery under general anesthesia? Protocol for a randomized controlled trial

Trials ◽  
2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Manisha Sahoo ◽  
Swagata Tripathy ◽  
Nitasha Mishra

Abstract 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, and success of the technique due to a difference in visualization and torque applied to the ETT after glottic visualization. We aim to compare the effect of 2 different sites of holding the ETT on time to intubation (TTI), intubation difficulty scale (IDS), and complications. Methods ASA 1–2 patients (>18 years) posted for surgery under general anesthesia, undergoing supervised intubation by anesthesia trainees (experience < 18 months), will be included. Patients with an anticipated difficult airway or unanticipated difficulty—CL grade 3 or 4 requiring the use of airway adjuncts—will be excluded. Patients will be randomized by a computer-generated number list, and allocation concealed with opaque sealed envelopes. The two sites for holding the ETT will be group 1 at 19 cm and group 2 at 24 cm. ETT marked at the selected site will be handed by the technician once the optimum position of the table, patient, and laryngoscopic view is confirmed by the intubator. The entire procedure will be video recorded. Two blinded assessors will independently review the videos to document the time to intubation and intubation difficulty score. A postoperative sore throat will be recorded. Sample size To detect a 20% difference in time to intubation between groups with a significance level of 5% and power of 85%, we will need a total of 298 patients. Accounting for data loss, we plan to recruit 180 patients in each group. Discussion This will be the first study to assess whether the site of holding the tube has any impact on the ease and time taken for intubation. The findings of this study will provide scientific evidence for suggesting an appropriate place for holding the ETT during direct laryngoscopy procedures. Trial registration Clinical Trials Registry India CTRI/2019/09/021201

2021 ◽  
Author(s):  
Manisha Sahoo ◽  
Swagata Tripathy ◽  
Nitasha Mishra

Abstract Background: Laryngoscopic endotracheal intubation (LEI) is a widely performed lifesaving technique. There are evidence and guidelines to help decide the optimal sized endotracheal tube (ET), laryngoscope, depth of insertion, and patient position for successful endotracheal intubation. We hypothesize that after glottic visualization, the point at which the ET is held will affect the time, ease, and success of the technique due to a difference in visualization and torque. We aim to compare two sites of holding the ET after optimal laryngeal-inlet visualization: time to intubation, rate of success of first pass intubation, intubation difficulty and complications.Methods: Supervised intubations on ASA 1-2 patients (>18 years) posted for surgery under general anesthesia performed by anesthesia trainees (experience <18 months) will be included. Patients with an anticipated difficult airway or unanticipated difficulty - CL grade > three or requiring the use of airway adjuncts will be excluded. A computer-generated numbers list will randomize patients; allocation concealed with opaque sealed envelopes. ET marked at the selected site will be handed to the intubator by the theatre-technician once she/he confirms the optimum laryngoscopic view. The entire procedure will be video recorded. Two blinded assessors will independently review the videos to document the time to intubation (TTI defined as the time from holding the ET to the removal of laryngoscope from the mouth after successful intubation) and intubation difficulty score. Postoperative sore throat and hoarseness will be recorded.Sample size: 54 experienced anesthetists were video-recorded during intubating. The site of holding ET and TTI were analyzed. The mean site was 3 SD 2.5 cm from the tip, yielding two sites for the study- 19 cm (Gr 1) and 24 cm (Gr 2). To detect a 20% difference in intubation time between groups, the confidence of 95%, and power 85%, we will need 298 patients: 180 per group after accounting for data loss.Discussion: This will be the first study to assess whether holding the tube at a particular site has any impact on the ease and time taken for intubation. This study's findings will provide the first scientific evidence for an appropriate place for holding the ET during LEI, which we feel will help trainees improve their LEI technique.Trial registration: CTRI/2019/09/021201, Clinical Trials Registry India. http://ctri.nic.in/Clinicaltrials/advsearch.php. Registered 12th September 2019,


2020 ◽  
Vol 9 (3) ◽  
pp. 671
Author(s):  
RyungA Kang ◽  
Ji Seon Jeong ◽  
Justin Sangwook Ko ◽  
Jaemyung Ahn ◽  
Mi Sook Gwak ◽  
...  

The optimal head position for GlideScope facilitated nasotracheal intubation has not yet been determined. We compared the neutral and sniffing positions to establish the degree of intubation difficulty. A total of 88 ASA I-II patients requiring nasotracheal intubation for elective dental surgery with normal airways were divided into two groups according to head position, neutral position (group N), and sniffing position (group S). The primary outcome was the degree of intubation difficulty according to the Intubation Difficulty Scale (IDS): Easy (IDS = 0), mildly difficult (IDS = 1 to 4), and moderately to severely difficult (IDS ≥ 5). Eighty-seven patients completed the study and their data were analyzed. The degree of intubation difficulty was significantly different between the two groups (p = 0.004). The frequency of difficult intubation (IDS > 0) was 12 (27.9%) in group N and 28 (63.6%) in group S (difference in proportion, 35.7%; 95% confidence interval [CI], 14.8 to 52.6%; p = 0.001). The neutral position facilitates nasotracheal intubation with GlideScope by aligning the nasotracheal tube and the glottis inlet more accurately than the sniffing position.


2021 ◽  
Vol 8 (41) ◽  
pp. 3573-3577
Author(s):  
AKhil Rao U.K. ◽  
Athira Soman ◽  
Anuradha Yadav ◽  
Yashwant R. ◽  
Sucheth Sharat

BACKGROUND Endotracheal intubation for the purpose of providing anaesthesia was first described by William Mc Ewan. Jackson1 stressed the importance of anterior flexion of the lower cervical spine, in addition to obvious extension of the atlanto-occipital joint. Sniffing position has been commonly advocated as a standard head positioning for direct laryngoscopy which is achieved by flexion of the neck on chest and extension of the head at the atlanto-occipital joint. Present study was designed to evaluate the glottis view and ease of intubation achieved with direct laryngoscopy in the sniffing position with that of 25 degree backup position in a study group of 100 patients divided in 2 groups of 50 each. METHODS This study is a controlled comparative study. Controlled trial in 50 consecutive patients in each group [Group I and Group II] was conducted on patients who underwent elective surgery under general anaesthesia. Inclusion Criteria - General anaesthesia with endotracheal intubation, Aged 18 to 60 years, American society of Anaesthesiologists (ASA) grades I and II. Exclusion Criteria - Patients with body mass index more than 30 kg/m2. 1. Bucked teeth. 2. Restricted neck movement. 3. Inter-incisor gap less than 35 mm. 4. Thyro-mental distance less than 6 mm. 5. Patients with risk of regurgitation and aspiration. 6. Pharyngeal pathology. 7. Limitation of anterior and posterior movement of mandible 8. Pregnant patients Groups wereGroup I – Sniffing position Group II– 25 degree back up position RESULTS The glottis visualization was assessed by Cormack Lehane grading which revealed that glottis view was better in 25 degree backup position than sniffing position. CONCLUSIONS In our prospective randomized study in a series of 50 patients undergoing general anaesthesia in SIMS & RC, intubation difficulty scale (IDS) score was better in 25 degree backup position than sniffing position. It implies glottis view is better in 25 degree backup position than sniffing position. KEYWORDS Sniffing Position, 25 Degree Backup Position, Laryngoscopy


Children ◽  
2021 ◽  
Vol 8 (12) ◽  
pp. 1171
Author(s):  
Min Hur ◽  
Jong Yeop Kim ◽  
Sang Kee Min ◽  
Kyuheok Lee ◽  
Young Ju Won ◽  
...  

We investigated the efficacy of the McGrath videolaryngoscope compared with the Macintosh laryngoscope in children with torticollis. Thirty children aged 1–10 years who underwent surgical release of torticollis were randomly assigned into the McGrath and Macintosh groups. Orotracheal intubation was performed by a skilled anesthesiologist. The primary outcome was the intubation time. The Cormack–Lehane grade, lifting force, intubation difficulty scale (IDS), difficulty level, and intubation failure rate were also assessed. The intubation time was significantly longer in the McGrath group than in the Macintosh group (31.4 ± 6.7 s vs. 26.1 ± 5.4 s, p = 0.025). Additionally, the Cormack–Lehane grades were comparable between the groups (p = 0.101). The lifting force and IDS were significantly lower in the McGrath group than in the Macintosh group (p < 0.001 and p = 0.022, respectively). No significant differences were observed with respect to endotracheal intubation difficulty and intubation success rate. Intubation-related complications were also not observed. In conclusion, compared with the Macintosh laryngoscope, the McGrath videolaryngoscope extended the intubation time and did not improve glottic visualization in children with torticollis, despite having a lesser lifting force, lower intubation difficulty scale, and similar success rate.


1970 ◽  
Vol 10 (10) ◽  
pp. 7
Author(s):  
Mónica San Juan Álvarez ◽  
María de la Flor Robledo ◽  
Concepción Rodríguez Bertos ◽  
L Pérez Rodríguez

Los videolaringoscopios son unos dispositivos, relativamente novedosos, introducidos en el mercado para facilitar la intubación de los pacientes al no ser necesario la alineación de los ejes oral, faríngeo y laríngeo. La principal limitación que encontramos en su uso es la dirección del tubo endotraqueal hacia la glotis. La escala Cormack-Lehane es el patrón de oro que utilizamos los anestesiólogos para valorar la visualización de la glotis con la laringoscopia directa. Actualmente no existe ninguna escala validad que permita describir la dificultad de intubación con los videolaringoscopios, probablemente por la variedad de dispositivos disponibles en el mercado. ABSTRACT Video laryngoscopes are relatively original devices placed in the market in order to make intubating patients easier as it´ s no  neccessary anymore the alignment of oral, pharyngeal and laryngeal shaft axis. The biggest constraint we face in its handling is the guide of the endotracheal tube to the glottis. Cormack-Lehane scale is the gold standar we anesthesiologists use to evaluate glottis display with direct laryngoscopy. Today there´s no valid scale able to describe intubation difficulty with video laryngoscopes, maybe because the huge ammount of different devices available.


Author(s):  
QY Goh ◽  
SA Lie ◽  
Z Tan ◽  
PYB Tan ◽  
SY Ng ◽  
...  

Introduction: During the COVID-19 pandemic, multiple guidelines have recommended the videolaryngoscope for tracheal intubation. However, there is no evidence that videolaryngoscope reduces time to tracheal intubation, which is important for COVID-19 patients with respiratory failure. Methods: To simulate intubation of COVID-19 patients, we randomised 28 elective surgical patients to be intubated with either the McGrath™ MAC videolaryngoscope or the direct laryngoscope by specialist anaesthetists donning 3M™ Jupiter™ powered air-purifying respirators (PAPR) and N95 masks. Primary outcome was time to intubation. Results: The median (IQR) times to intubation were 61s (37–63 s) and 41.5s (37–56 s) in the videolaryngoscope and direct laryngoscope groups respectively (p = 0.35). The closest mean (SD) distances between the anaesthetist and the patient during intubation were 21.6 cm (4.8 cm) and 17.6 cm (5.3 cm) in the videolaryngoscope and direct laryngoscope groups, respectively (p = 0.045). There were no significant differences in the median intubation difficulty scale scores, proportion of successful intubation at first laryngoscopic attempt and proportion of intubations requiring adjuncts. Intubations for all the patients were successful with no adverse event. Conclusion: There was no significant difference in the time to intubation by specialist anaesthetists who were donned in PAPR and N95 masks on elective surgical patients with either the McGrath™ videolaryngoscope or direct laryngoscope. The distance between the anaesthetist and patient was significantly further with the videolaryngoscope. The direct laryngoscope could be an equal alternative to videolaryngoscope for specialist anaesthetists when resources are limited or disrupted due to the pandemic.


2019 ◽  
Vol 19 (2) ◽  
Author(s):  
Dino Irawan ◽  
Nopian Hidayat

Abstrak. Penelitian ini berjudul perbandingan tingkat kenyamanan pasca pembiusan umum dengan endotracheal tube antara pemberian dexametasone intravena dan lidocaine spray di RSUD Arifin Achmad Provinsi  Riau. Tingkat kenyamanan berupa nyeri tenggorok pada pasien yang menjalani pembiusan umum dengan intubasi endotrakeal dapat dipengaruhi oleh beberapa hal yaitu obat-obatan yang diberikan, teknik insersi, tekanan cuff dan manajemen setelah insersi.Nyeri tenggorok pada pasien yang menjalani anestesi umum dengan intubasi endotrakeal pada umumnya tidak berakibat fatal dan akan menghilang dalam 48-72 jam setelah operasi tetapi hal ini dapat menyebabkan gangguan yang cukup berarti bagi pasien, menambah lama dan biaya rawatan pasien di rumah sakit serta meninggalkan kesan buruk terhadap operasi. Penelitian ini menggunakan pendekatan randomized clinical controlled trial dengan rancangan eksperimental yang dilakukan pada 104 pasien yang menjalani anestesi umum dengan endotrakeal tube di RSUD Arifin Achmad Provinsi Riau pada bulan September-Oktober 2019. Pada hasil penelitian didapatkan bahwa pemberian dexametasone intravena sebelum tindakan intubasi endotrakeal lebih efektif dalam mencegah nyeri tenggorok pasca operasi dibandingkan lidocaine spray (19.2% untuk Dexametasone intravena dan 29.8% pada Lidocaine spray). Secara statistik, perbedaan kejadian nyeri tenggorok antara kelompok Dexametasone intravena dan Lidocaine spray adalah bermakna pada skoring 1 jam post operasi (p 0.05) dan tidak bermakna pada skoring 24 jam post operasi (p0.05). Insidensi nyeri tenggorok terbanyak berdasarkan usia adalah pada kelompok usia 46-55 tahun dan 55-65 tahun, berdasarkan jenis kelamin adalah lebih banyak pada perempuan dibandingkan laki-laki, dan lebih banyak pada pasien yang mempunyai riwayat merokok. Kata kunci: nyeri tenggorok, dexametasone intravena, lidocaine spray, RSUD Arifin Achmad Provinsi Riau Abstract. This study is about the comparison of the level of comfort after general anesthesia with an endotracheal tube between administration of intravenous dexametasone and lidocaine spray in Arifin Achmad General Hospital of Riau Province. The level of comfort in the form of sore throat in patients undergoing general anesthesia with endotracheal intubation can be influenced by several things such as administration of drugs, insertion techniques, cuff pressure and management after insertion. Sore throat in patients undergoing general anesthesia with endotracheal intubation is generally not fatal and will disappear within 48-72 hours after surgery but this can cause significant disruption to the patient, increase the length and cost of patient care in the hospital and leave bad impression from surgery. This study is a randomized clinical controlled trial with an experimental design conducted on 104 patients undergoing general anesthesia with endotracheal tube at Arifin Achmad General Hospital in Riau Province in September-October 2019. The study found that administration of intravenous dexametasone before endotracheal intubation is more effective in preventing postoperative sore throat compared to lidocaine spray (19.2% for intravenous Dexametasone and 29.8% in Lidocaine spray). Statistically, the difference in the incidence of sore throat between the intravenous Dexametasone group and Lidocaine spray was significant at 1 hour postoperative scoring (p 0.05) and not significant at 24 hour postoperative scoring (p 0.05). The highest incidence of sore throat by age is in the age group 46-55 years and 56-65 years, more frequent in women than men, and more frequent in patients who have a history of smoking. Keywords: sore throat, intravenous dexametasone, lidocaine spray, Arifin Achmad General Hospital Riau Province


2005 ◽  
Vol 102 (2) ◽  
pp. 315-319 ◽  
Author(s):  
Alexis F. Turgeon ◽  
Pierre C. Nicole ◽  
Claude A. Trépanier ◽  
Sylvie Marcoux ◽  
Martin R. Lessard

Background Cricoid pressure (CP) is applied during induction of anesthesia to prevent regurgitation of gastric content and pulmonary aspiration. However, it has been suggested that CP makes tracheal intubation more difficult. This double-blind randomized study evaluated the effect of CP on orotracheal intubation by direct laryngoscopy in adults. Methods Seven hundred adult patients undergoing general anesthesia for elective surgery were randomly assigned to have a standardized CP (n = 344) or a sham CP (n = 356) during laryngoscopy and intubation. After anesthesia induction and complete muscle relaxation, a 30-s period was allowed to complete intubation with a Macintosh No. 3 laryngoscope blade. The primary endpoint was the rate of failed intubation at 30 s. The secondary endpoints included the intubation time, the Cormack and Lehane grade of laryngoscopic view, and the Intubation Difficulty Scale score. Results Groups were similar for demographic data and risk factors for difficult intubation. The rates of failed intubation at 30 s were comparable for the two groups: 15 of 344 (4.4%) and 13 of 356 (3.7%) in the CP and sham CP groups, respectively (P = 0.70). The grades of laryngoscopic view and the Intubation Difficulty Scale score were also comparable. Median intubation time was slightly longer in the CP group than in the sham CP group (11.3 and 10.4 s, respectively, P = 0.001). Conclusions CP applied by trained personnel does not increase the rate of failed intubation. Hence CP should not be avoided for fear of increasing the difficulty of intubation when its use is indicated.


2012 ◽  
Vol 9 (1) ◽  
pp. 58-63 ◽  
Author(s):  
B Bhattarai ◽  
S K Shrestha ◽  
S Kandel

Background The ability of good glottis visualization during direct laryngoscopy is major determinant of easy tracheal intubation. Sniffing position for laryngoscopy is considered as gold standard and ideal position. Several studies have questioned the validation of sniffing potion. Objectives This study aims to compare relative efficacy of sniffing position and simple head extension for visualization of glottis during direct laryngoscopy. Methods Four hundred patients undergoing elective surgery under general anesthesia requiring endotracheal intubation were randomized into two groups and study was concluded. Glottic visualization was assessed using modified Cormack and Lehane classification. After laryngoscopy, tracheal intubation was performed and intubation difficulty scale was noted. Results Both the groups were comparable regarding glottis visualization. Both the groups were comparable in demographic profiles. All the intubation difficulty scale variables were comparable in both the groups except N3. Total Intubation Difficulty Score was better in sniffing position than in simple head extension group. Conclusion Glottic visualization and intubation difficulty score was better in sniffing position as compared to simple head extension.http://dx.doi.org/10.3126/kumj.v9i1.6265 Kathmandu Univ Med J 2011;9(1):58-63


Esculapio ◽  
2020 ◽  
Vol 16 (03, july 2020-Septmber 2020) ◽  
Author(s):  
Shaukat Hussain ◽  
Muhammad Arslan ◽  
Muhammad Tayyab ◽  
Isfand Yar Khan

Objective: To compare the outcome of salbutamol nebulization with controls (normal saline) in transient tachypnea of newborn. Methods: In this randomized controlled trial 284 (142 in each group) neonates were included with gestational age above 35 weeks of any gender. Study was conducted in Department of Pediatrics Holy Family Hospital Rawalpindi. Sampling technique was consecutive non probability sampling. Duration of study was 6 months. Sample size had been calculated using WHO calculator; Significance level 5%, Power of test 80%, Population mean 5.4, Test value of population mean 4.8, Standard Deviation 1.8. At admission complete blood picture, C-reactive protein and chest x-ray were done. Group-1 received salbutamol nebulization at a dose of 0.15mg / kg / dose for 10 minutes in 2ml normal saline QID while Group-2 received only normal saline nebulization 2ml QID in 24 hours. Double blinding was ensured and in case of any side effects of salbutamol (tachycardia, arrhythmias and hypoglycemia) treatment was stopped immediately and managed accordingly. Results: In this study, comparison of outcome of inhaled salbutamol with controls in transient tachypnea of newborn shows that respiratory rate per minute was 50.15+2.34 in Group-1 and 64.92+2.70 in Group-2, p value was 0.0001, heart rate per minute in Group-1 was recorded as 120.08+2.36 and 134.79+3.27 in Group- 2, p value was 0.0001, oxygen saturation(%) was 97.27+0.92 in Group-1 and 83.28+1.81 in Group-2, p value was 0.0001, duration of oxygen therapy(hours) was recorded as 15.49+1.84 in Group-1 and 27.78+5.57 in Group-2, value of p was 0.0001, duration of hospitalization(days) was recorded as 2.03+0.45 in Group-1 and 5.07+0.72 in Group-2 while value of P was 0.0001 Conclusion: Salbutamol Nebulization is more effective than normal saline in TTN. Key Words: Transient Tachypnea of newborn, management, inhaled salbutamol, outcome.


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