Effects of Head Positions on Awake Orotracheal Intubation Via Fiberoptic-Bronchoscope: A Randomized Controlled Trial

Abstract Background: There are many factors affect the success rate of awake orotracheal intubation via fiberoptic bronchoscope. We performed this study to investigate the effects and safety of three head positions on awake orotracheal intubation via fiberoptic bronchoscope. Methods: Seventy-five adult patients with anticipated difficult airway, received general anaesthesia and undergoing awake orotracheal intubation were included in this study. According to the head position, the patients were randomized allocated to neutral position group (NP group), sniffing position group (SP group) or extension position group (EP group). After conscious sedation the patients were intubated by an experienced anesthesiologist. The time to view the vocal cords, the time to insert the tracheal tube into the trachea, the percentage of glottic opening scores (POGO) and the visual analog scale (VAS) scores for ease experienced of passing the tracheal tube through the glottis, the hemodynamic changes during intubation and the adverse events after surgery were recorded. Results: The time to view the vocal cords was significantly shorter and the POGO scores was significantly higher in the EP group compared with the other two groups (P<0.05); the SpO2 immediate after intubation was higher in the EP group compared with SP group (P<0.05) and the SpO2 before intubation was higher in the EP group compared with NP group (P<0.05), while at other time points the SpO2 had no significant difference among groups. The time to tracheal intubation, the VAS scores for passing the tracheal tube through glottis, the coughing scores of patients when inserted fiberoptic bronchoscope into the trachea and inserted the tracheal tube into the trachea over fiberoptic bronchoscope had no significant differences among groups (P>0.05). There were also no significant differences among the groups with regard to the incidence of postoperative complications, mean arterial pressure and heart rate at each time point (P>0.05). Conclusions: Extension position had a best view of glottic opening than neutral position or sniffing position during awake orotracheal intubation via fiberoptic bronchoscope, so extension position was recommended as the starting head position for awake orotracheal intubation using fiberoptic bronchoscope.Trial registration: Clinical Trials.gov. no. NCT 02792855. Registered at https://register.clinicaltrials.gov on 23 september 2017.

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Effects of head positions on awake fiberoptic bronchoscope oral intubation: a randomized controlled trial

BMC Anesthesiology ◽

10.1186/s12871-021-01397-4 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Zhuo Liu ◽

Li Zhao ◽

Zhongfeng Ma ◽

Meiqi Liu ◽

Xiaohang Qi ◽

...

Keyword(s):

Tracheal Tube ◽

Orotracheal Intubation ◽

Neutral Position ◽

Fiberoptic Bronchoscope ◽

Glottic Opening ◽

Vocal Cords ◽

Oral Intubation ◽

Vas Scores ◽

Head Positions ◽

Position Group

Abstract Background There are many factors affecting the success rate of awake orotracheal intubation via fiberoptic bronchoscope. We performed this study was to investigate the effects of head positions on awake Fiberoptic bronchoscope oral intubation. Methods Seventy-five adult patients, received general anaesthesia were included in this study. After written informed consent, these patients were undergoing awake orotracheal intubation via fiberoptic-bronchoscope and according to the head position, the patients were randomized allocated to neutral position group (NP group), sniffing position group (SP group) or extension position group (EP group). After sedation the patients were intubated by an experienced anesthesiologist. The time to view the vocal cords, the percentage of glottic opening scores (POGO), the time to insert the tracheal tube into trachea and the visual analog scale (VAS) scores for ease experienced of passing the tracheal tube through glottis, the hemodynamic changes and the adverse events after surgery were recorded. Results The time to view the vocal cords was significantly shorter and the POGO scores was significantly higher in the EP group compared with the other two groups (P < 0.05); The SpO2 in the EP group was higher than NP group at before intubation and higher than SP group and NP group at immediate after intubation (P < 0.05); The time to insert the tracheal tube into trachea, the VAS scores for passing the tracheal tube through glottis, the coughing scores had no significant differences among groups (P > 0.05). There were also no significant differences regard to the incidence of postoperative complications, mean arterial pressure and heart rate among the groups (P > 0.05). Conclusions The head at extension position had a best view of glottic opening than neutral position or sniffing position during awake Fiberoptic bronchoscope oral intubation, so extension position was recommended as the starting head position for awake Fiberoptic bronchoscope oral intubation. Trial registration Clinical Trials.gov. no. NCT02792855. Registered at https://register.clinicaltrials.gov on 23 september 2017.

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Comparison of vocal cord view between neutral and sniffing position during orotracheal intubation using fiberoptic bronchoscope: A prospective, randomized cross over study

10.21203/rs.1.13/v1 ◽

2018 ◽

Author(s):

Sanghee Park ◽

Hyung Gon Lee ◽

Jeong Il Choi ◽

Seongheon Lee ◽

Eun-A Jang ◽

...

Keyword(s):

Vocal Cord ◽

Orotracheal Intubation ◽

Fiberoptic Intubation ◽

Neutral Position ◽

Fiberoptic Bronchoscope ◽

Glottic Opening ◽

Head Positioning ◽

The Mean ◽

Head Positions ◽

To Receive

Abstract Background: Limitation of sight during endotracheal intubation is a major complicating factor using fiberoptic bronchoscope. Thus, maneuvers to relieve such obstructions are recommended. There have been no studies to determine whether the sniffing or neutral position is superior for this purpose. Therefore, this study was performed to examine the effects of these two positions including vocal core view. Methods: Fifty-four patients scheduled to receive general anesthesia by orotracheal intubation were eligible for inclusion in the study with informed consent. After confirmation of proper head positioning depending on the group, the view of the vocal cord was acquired in each position. Images were reviewed using the percentage of glottic opening (POGO) score. Results: A total of 106 images of vocal cords from 53 patients were obtained. The mean POGO scores were 26.65 ± 30.18 for the sniffing position and 37.29 ± 32.56 for the neutral position (P = 0.002). Neutral position increased POGO score in 31 patients and decreased POGO score in 13 patients compare to sniffing position (p = 0.017). There were no significant differences between the two head positions with regard to intubation time or degree of convenience during intubation. Conclusions: Neutral position improved the view of glottic opening than sniffing position during oral fiberoptic intubation. However, there was no difference in the difficulty of tube insertion between the two positions. Trial registration: Clinical Trials.gov identifier: NCT02931019, registered on October 12, 2016

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Comparison of vocal cord view between neutral and sniffing position during orotracheal intubation using fiberoptic bronchoscope: A prospective, randomized cross over study

10.21203/rs.1.13/v3 ◽

2019 ◽

Author(s):

Sanghee Park ◽

Hyung Gon Lee ◽

Jeong Il Choi ◽

Seongheon Lee ◽

Eun-A Jang ◽

...

Keyword(s):

Vocal Cord ◽

Upper Airway ◽

Orotracheal Intubation ◽

Fiberoptic Intubation ◽

Neutral Position ◽

Fiberoptic Bronchoscope ◽

Glottic Opening ◽

Head Positioning ◽

Head Positions ◽

To Receive

Abstract Background: In intubation using fiberoptic bronchoscope (FOB), partial or complete obstruction of upper airway makes the FOB insertion difficult. Thus, maneuvers to relieve such obstructions are recommended. There have been no studies to determine whether the sniffing or neutral position is superior for this purpose. Therefore, this study was performed to examine the effects of these two positions including vocal cord view. Methods: Fifty-four patients scheduled to receive general anesthesia by orotracheal intubation were eligible for inclusion in the study with informed consent. After confirmation of proper head positioning depending on the group, the view of the vocal cord was acquired in each position. Images were reviewed using the percentage of glottic opening (POGO) score. Results: A total of 106 images of vocal cords from 53 patients were obtained. The mean of difference of POGO score was 11.09, higher for the neutral position and standard deviation was 23.73 (p = 0.002). Neutral position increased POGO score in 31 patients and decreased POGO score in 13 patients compare to sniffing position (p = 0.017). There were no significant differences between the two head positions with regard to intubation time or degree of convenience during intubation. Conclusions: Neutral position improved the view of glottic opening than sniffing position during oral fiberoptic intubation. However, there was no difference in the difficulty of tube insertion between the two positions. Trial registration: Clinical Trials.gov identifier: NCT02931019, registered on October 12, 2016

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Comparison of vocal cord view between neutral and sniffing position during orotracheal intubation using fiberoptic bronchoscope: A prospective, randomized cross over study

10.21203/rs.1.13/v2 ◽

2018 ◽

Author(s):

Sanghee Park ◽

Hyung Gon Lee ◽

Jeong Il Choi ◽

Seongheon Lee ◽

Eun-A Jang ◽

...

Keyword(s):

Vocal Cord ◽

Upper Airway ◽

Orotracheal Intubation ◽

Fiberoptic Intubation ◽

Neutral Position ◽

Fiberoptic Bronchoscope ◽

Glottic Opening ◽

Head Positioning ◽

Head Positions ◽

To Receive

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Neutral Position Facilitates Nasotracheal Intubation with a GlideScope Video Laryngoscope: A Randomized Controlled Trial

Journal of Clinical Medicine ◽

10.3390/jcm9030671 ◽

2020 ◽

Vol 9 (3) ◽

pp. 671

Author(s):

RyungA Kang ◽

Ji Seon Jeong ◽

Justin Sangwook Ko ◽

Jaemyung Ahn ◽

Mi Sook Gwak ◽

...

Keyword(s):

Controlled Trial ◽

Nasotracheal Intubation ◽

Head Position ◽

Neutral Position ◽

Dental Surgery ◽

Intubation Difficulty ◽

Difficulty Scale ◽

Nasotracheal Tube ◽

Glidescope Video Laryngoscope ◽

Position Group

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.

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Study of the “Sniffing Position” by Magnetic Resonance Imaging

Anesthesiology ◽

10.1097/00000542-200101000-00017 ◽

2001 ◽

Vol 94 (1) ◽

pp. 83-86 ◽

Cited By ~ 95

Author(s):

Frédéric Adnet ◽

Stephen W. Borron ◽

Jean Luc Dumas ◽

Frédéric Lapostolle ◽

Michel Cupa ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Alpha Angle ◽

Orotracheal Intubation ◽

Head Position ◽

Simple Extension ◽

Neutral Position ◽

Resonance Imaging ◽

Beta Angle ◽

Adult Volunteers

Background The "sniffing position" is widely considered essential to the performance of orotracheal intubation and has become the cornerstone of training in anesthesiology. However, the anatomic superiority of this patient head position has not been established. Methods Eight healthy young adult volunteers underwent magnetic resonance imaging scanning in three anatomic positions: head in neutral position, in simple extension, and in the "sniffing position" (neck flexed and head extended by means of a pillow). The following measurements were made on each scan: (1) the axis of the mouth (MA); (2) the pharyngeal axis (PA); (3) the laryngeal axis (LA); and (4) the line of vision. The various angles between these axes were defined: alpha angle between the MA and PA, beta angle between PA and LA, and delta angle between line of vision and LA. Results Both simple extension and sniffing positions significantly improved (P < 0.05) the delta angle associated with best laryngoscopic view. Our results show that the beta value increases significantly (P < 0.05) when the head position is shifted from the neutral position (beta = 7 +/- 6 degrees ) to the sniffing position (beta = 13 +/- 6 degrees ), and the alpha value slightly (but significantly) decreases (from 87 +/- 10 degrees to 63 +/- 11 degrees; P < 0.05). Anatomic alignment of the LA, PA, and MA axes is impossible to achieve in any of the three positions tested. There were no significant differences between angles observed in simple extension and sniffing positions. Conclusions The sniffing position does not achieve alignment of the three important axes (MA, PA, and LA) in awake patients with normal airway anatomy.

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Appropriate Head Position for Nasotracheal Intubation by Using Lightwand Device (Trachlight)

Anesthesia Progress ◽

10.2344/0003-3006-61.2.47 ◽

2014 ◽

Vol 61 (2) ◽

pp. 47-52

Author(s):

Yozo Manabe ◽

Shigeru Iwamoto ◽

Mika Seto ◽

Kazuna Sugiyama

Keyword(s):

Nasotracheal Intubation ◽

Head Position ◽

Ordinal Scale ◽

Neutral Position ◽

Intubation Time ◽

Point Scale ◽

Intubation Difficulty ◽

Significant Difference ◽

The Relationship ◽

Position Group

Abstract The purpose of this study was to determine the relationship between the head position and the subsequent ease of nasotracheal intubation by using the lightwand device Trachlight (TL). Patients requiring nasotracheal intubation were subdivided into 3 groups according to the intubated head position (group S: sniffing position; group E: extension position; and group N: neutral position). The number of attempts, the total intubation time, and the failures of the TL intubation were recorded. Intubation difficulty by means of TL was assessed by the ordinal 6-point scale. Of the 300 patients enrolled in the study, TL intubation was successful in 91.3% of them. There was no significant difference in the success rate of the first attempt between the groups. No correlation between the ordinal scale and the head position was observed. The total intubation time and the ratio of “unsuccessful” cases were not significantly different among the 3 groups. TL is an effective alternative for patients who require nasotracheal intubation. Our study did not determine the most favorable head position for nasotracheal intubation with the TL, so we recommend that nasotracheal intubation with TL be started with the head in the neutral position and then changed to a more appropriate position, if necessary, on an individual basis.

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Head Position and Posturography: A Novel Biomarker to Identify Concussion Sufferers

Brain Sciences ◽

10.3390/brainsci10121003 ◽

2020 ◽

Vol 10 (12) ◽

pp. 1003

Author(s):

Frederick Robert Carrick ◽

Guido Pagnacco ◽

Melissa Hunfalvay ◽

Sergio Azzolino ◽

Elena Oggero

Keyword(s):

Balance Control ◽

Normal Subjects ◽

Neutral Plane ◽

Clinical Test ◽

Standard Group ◽

Neutral Position ◽

Dynamic Posturography ◽

Post Concussion Syndrome ◽

Eyes Open ◽

Head Positions

Balance control systems involve complex systems directing muscle activity to prevent internal and external influences that destabilize posture, especially when body positions change. The computerized dynamic posturography stability score has been established to be the most repeatable posturographic measure using variations of the modified Clinical Test of Sensory Integration in Balance (mCTSIB). However, the mCTSIB is a standard group of tests relying largely on eyes-open and -closed standing positions with the head in a neutral position, associated with probability of missing postural instabilities associated with head positions off the neutral plane. Postural stability scores are compromised with changes in head positions after concussion. The position of the head and neck induced by statically maintained head turns is associated with significantly lower stability scores than the standardized head neutral position of the mCTSIB in Post-Concussion Syndrome (PCS) subjects but not in normal healthy controls. This phenomenon may serve as a diagnostic biomarker to differentiate PCS subjects from normal ones as well as serving as a measurement with which to quantify function or the success or failure of a treatment. Head positions off the neutral plane provide novel biomarkers that identify and differentiate subjects suffering from PCS from healthy normal subjects.

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Head position classification of medical imaging studies: an assessment and development of a protocol

Dentomaxillofacial Radiology ◽

10.1259/dmfr.20190220 ◽

2020 ◽

Vol 49 (4) ◽

pp. 20190220

Author(s):

Courtney A. Miller ◽

Yen Lee ◽

Gregory D. Avey ◽

Houri K. Vorperian

Keyword(s):

Medical Imaging ◽

Head And Neck ◽

Neck Region ◽

Head Position ◽

Imaging Studies ◽

Distance Measurements ◽

Single Measure ◽

Multiple Measures ◽

Flexion Extension ◽

Head Positions

Objectives To determine the optimal approach to reliably classify head position of head and neck medical imaging studies as flexion, neutral or extension for use in craniofacial and orthodontic research. Methods and material: A prospective study scanned six participants in flexed, neutral and extended head positions. Additionally, a retrospective dataset of 46 CT studies were visually classified into six categories: flexion, neutral-flexion, neutral, neutral-extension, extension and flexion-extension. 14 landmarks were placed in the head and neck region of all studies to calculate 17 head position angle and distance measurements. Assessment of head position classification was performed for each measure, as well as all measures together using GUIDE forest. Results: No single measure was sufficient to reliably classify head position in both retrospective and prospective imaging studies. Therefore, this study developed a head position protocol that considers multiple measures using two hybrid predictive models, to classify head position. Compared to visual assessment of head position, this protocol classified the imaging studies into the four head position categories with 82% neutral sensitivity and 100% neutral precision where the three neutral groups (neutral-flexion, neutral and neutral-extension) were grouped together. Conclusion: This study established a novel head position classification protocol that uses multiple measures accounting for both head and neck positions to reliably classify head positions in imaging studies as: flexion, neutral or extension. Given the limitation that no single measure reliably classified head position, this protocol is strongly recommended to researchers who need to account for head position to reach valid conclusions.

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A new self-designed “tongue root holder” device to aid fiberoptic intubation

Clinical Oral Investigations ◽

10.1007/s00784-020-03297-2 ◽

2020 ◽

Vol 24 (12) ◽

pp. 4335-4342

Author(s):

Xiaofei Cao ◽

Junbei Wu ◽

Yin Fang ◽

Zhengnian Ding ◽

Tao Qi

Keyword(s):

Risk Factors ◽

Difficult Airway ◽

Soft Palate ◽

Elective Surgery ◽

Upper Airway ◽

Orotracheal Intubation ◽

Fiberoptic Intubation ◽

Fiberoptic Bronchoscope ◽

Airway Clearance ◽

Jaw Thrust Maneuver

Abstract Objective In this study, we aimed to assess the feasibility of fiberoptic intubation (FOI), using a new, self-designed, “tongue root holder” device, in combination with the jaw thrust maneuver. Methods Three hundred patients undergoing elective surgery requiring orotracheal intubation were enrolled. Patients presented at least one or more risk factors for difficult airway. The patients were randomly allocated at a 1:1 ratio to one of two groups: group L, FOI with tongue root holder, or group C, standard FOI. Orotracheal FOI was performed after commencement of anesthesia. The jaw thrust maneuver was applied in both groups to facilitate advancement of the fiberoptic bronchoscope. The primary endpoint was the feasibility of FOI. The secondary endpoints were number of attempts, time to intubation, and airway clearance at the soft palate and epiglottis levels. Results The FOI was achieved in all 150 patients in group L, significantly higher than that in group C (100% vs 95.3%; P = 0.015). Less attempts of intubation were made in group L (P = 0.039). Mean time to successful intubation on the first attempt was shorter in group L (P < 0.001). The mean times to view the vocal cord and carina were also shorter in group L (P = 0.011 and P < 0.001, respectively). Airway clearance was better in group L at both the soft palate and the glottis levels (P = 0.010 and P = 0.038, respectively). Conclusions This study shows that FOI is feasible with the newly introduced, self-designed, “tongue root holder” device, when combined with the jaw thrust maneuver in patients with risk factors for difficult airway. The device also provides better airway clearance, less intubation attempts, and shorter time to intubation at first attempt. Clinical relevance Fiberoptic bronchoscope has been the gold standard for routine management of difficult airway. A technique to open the airway is introduced to reduce the incidence rate of upper airway obstruction.

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