Comparison between GlideRite® rigid stylet and Parker Flex-It™ stylet to facilitate GlideScope intubation in simulated difficult intubation: a randomized controlled study

Background: The GlideScope® videolaryngoscope (GVL) is widely used in patients with difficult airways and provides a good glottic view. However, the acute angle of the blade can make insertion and advancement of an endotracheal tube (ETT) more difficult than direct laryngoscopy, and the use of a stylet is recommended. This randomized controlled trial compared Parker Flex-It™ stylet (PFS) with GlideRite® rigid stylet (GRS) to facilitate intubation with the GVL in simulated difficult intubations. Methods: Fifty-four patients were randomly allocated to undergo GVL intubation using either GRS (GRS group) or PFS (PFS group). The total intubation time (TIT), 100-mm visual analog scale (VAS) for ease of intubation, success rate at the first attempt, use of laryngeal manipulation, tube advancement rate by assistant, and complications were recorded. Results: There was no significant difference between the GRS and PFS groups regarding TIT (50.3 ± 12.0 s in the GRS group and 57.8 ± 18.8 s in the PFS group, P = 0.108). However, intubation was more difficult in the PFS group than in the GRS group according to VAS score (P = 0.011). Cases in which the ETT was advanced from the stylet by an assistant, were more frequent in the GRS group than in the PFS group (P = 0.002). The overall incidence of possible complications was not significantly different. Conclusions: In patients with a simulated difficult airway, there was no difference in TIT using either the PFS or GRS. However, endotracheal intubation with PFS is more difficult to perform than GRS.

Tracheal Tube-Mounted Camera Assisted Intubation vs. Videolaryngoscopy in Expected Difficult Airway: A Prospective, Randomized Trial (VivaOP Trial)

Background: Tracheal intubation in patients with an expected difficult airway may be facilitated by videolaryngoscopy (VL). The VL viewing axis angle is specified by the blade shape and visualization of the larynx may fail if the angle does not meet anatomy of the patient. A tube with an integrated camera at its tip (VST, VivaSight-SL) may be advantageous due to its adjustable viewing axis by means of angulating an included stylet.Methods: With ethics approval, we studied the VST vs. VL in a prospective non-inferiority trial using end-tidal oxygen fractions (etO2) after intubation, first-attempt success rates (FAS), visualization assessed by the percentage of glottis opening (POGO) scale, and time to intubation (TTI) as outcome parameters.Results: In this study, 48 patients with a predicted difficult airway were randomized 1:1 to intubation with VST or VL. Concerning oxygenation, the VST was non-inferior to VL with etO2 of 0.79 ± 0.08 (95% CIs: 0.75–0.82) vs. 0.81 ± 0.06 (0.79–0.84) for the VL group, mean difference 0.02 (−0.07 to 0.02), p = 0.234. FAS was 79% for VST and 88% for VL (p = 0.449). POGO was 89 ± 21% in the VST-group and 60 ± 36% in the VL group, p = 0.002. TTI was 100 ± 57 s in the VST group and 68 ± 65 s in the VL group (p = 0.079). TTI with one attempt was 84 ± 31 s vs. 49 ± 14 s, p < 0.001.Conclusion: In patients with difficult airways, tracheal intubation with the VST is feasible without negative impact on oxygenation, improves visualization but prolongs intubation. The VST deserves further study to identify patients that might benefit from intubation with VST.

The Application of a SaCoVLMTM Visual Intubation Laryngeal Mask for the Management of Difficult Airways in Morbidly Obese Patients: Case Report

We report insertion of the SaCoVLMTM in three awake morbidly obese patients (BMI 46. 7–52.1 kg/m2). The patients were given intravenous atropine and midazolam injections after entering the operating room and then inhaled an anesthetic with 2% lidocaine atomization. After SaCoVLMTM insertion while patients were awake, when the vocal cords were visualized, controlled anesthetic induction commenced with spontaneous ventilation. The entire anesthesia induction and intubation process was completed under visualization, and no adverse events such as hypoxemia occurred. No patient had an unpleasant recall of the procedure. We conclude that the SaCoVLMTM is easy to use, well tolerated and suitable for awake orotracheal intubation in patients with known difficult airways.

Upper lip bite test compared to modified Mallampati test in predicting difficult airway in obstetrics: A prospective observational study

Difficult airway and intubation can have dangerous sequela for patients if not managed promptly. This issue is even more challenging among obstetric patients. Several studies have aimed to determine whether the test to predict a difficult airway or difficult intubation, is higher in accuracy. This study aims to compare the upper lip bite test with the modified Mallampati test in predicting difficult airway among obstetric patients. During this prospective observational study, 184 adult pregnant women, with ASA physical status of II, were enrolled. Difficult intubations of Cormack-Lehane grade III and IV were defined as difficult airways and difficult intubation in this study. Upper lip bite test, modified Mallampati test, thyromental distance and sternomental distance were noted for all patients. Modified Mallampati test, upper lip bite test and sternomental distance had highest specificity. Based on regression analysis, body mass index and Cormack-Lehane grade have a significant association. Modified Mallampati test was the most accurate test for predicting difficult airway. The best cut-off points of thyromental distance and sternomental distance in our study were 5cm and 15cm, respectively, by receiver operating characteristic curve analysis. Based on the results of the present study, it can be concluded that in the obstetric population, modified Mallampati test is practically the best test for predicting difficult airway. However, combining this test with upper lip bite test, thyromental distance and sternomental distance might result in better diagnostic accuracy.

The Radiographic “Air Sign” in Neonatal Mandibular Distraction Osteogenesis

Timing of extubation on post-mandibular distraction osteogenesis (MDO) surgery is critical, given that at baseline these infants have difficult airways and failed extubation requires either re-intubation of an already complex airway with a fragile, recently osteotomized mandible, or adjunctive airway measures such as CPAP that may apply unwanted pressure to the surgical site. Thus, the goal is to plan extubation when the risk of failure is minimal. Currently, there is a void in the literature addressing the timing of extubation post-MDO and no objective sign of extubation readiness has been elucidated. This study describes a simple clinical pearl to assist in the evaluation of extubation readiness in these patients. Postoperatively, we obtain weekly radiographs to assess distractor stability and advancement, and to assess for the “Air Sign”. The Air Sign describes a radiolucent space (air) visualized in the oropharynx on lateral radiographs, likely indicating that the tongue based airway obstruction has been relieved by mandibular advancement.

Managing Known Difficult Airways in Obstetric Patients Using a Flexible Bronchoscope and IRRIS: A Case-Illustrated Guide for Nonexpert Anesthesiologists, without Surgical Backup

Pregnancy is associated with anatomical and physiological changes leading to potential difficult airway management. Some pregnant women have known difficult airways and cannot be intubated even with a hyperangulated videolaryngoscope. If neuraxial techniques are also impossible, awake tracheal intubation with a flexible bronchoscope may be one of the few available options to avoid more invasive techniques. The Infrared Red Intubation System (IRRIS) may help nonexpert anesthesiologists in such situations and may enhance the chance of successful intubation increasing safety for the mother and the fetus, especially in hospitals without the ear, nose, and throat surgical backup.

A Survey of Residency Directors in Academic Trauma Centers for Policies on Airway Management in The Trauma Ward

Background Despite its presence as a critical procedure in the trauma setting, airway management is not performed uniformly, varying between institutions, particularly with personnel involved in decision-making. Past literature has noted a trend in which emergency medicine physicians assumed greater responsibility for primary management of airways in the trauma ward. In addition, many institutions have adopted tiered activation systems for traumas in order to improve patient care, deploying resources more effectively. In this study, a survey of residency directors was deployed to assess trends in airway management. Methods A validated survey was distributed to residency directors in anesthesiology, general surgery and emergency medicine in 190 Level I trauma centers in the United States. Questions assessed personnel management, complication tracking and difficult airway prediction factors, amongst other considerations for airway management in the trauma bay. Results Respondents completed the survey at a rate of 23.8% of those solicited. A majority of respondents indicated that emergency medicine physicians are primary airway managers in the trauma bay and that their institutions utilize tiered trauma activation systems at 77.4% and 95.6% respectively. Anesthesia providers were immediately available in 81% of respondent institutions with inconclusive data regarding protocols for delineating anesthesia involvement in difficult airways. More than a third of respondents indicated their institution either does not track airway complications or they did not know if complications were tracked. Finally, nine different criteria were used in varying degrees by respondents’ institutions to predict the presence of a difficult airway, including such factors as head/face trauma, airway fluid and obesity. Conclusion The trend towards airway management by emergency medicine physicians in the trauma bay continues, with anesthesia personnel available in many situations to assist in complicated patients. Complication tracking for airway management remains inconsistent, as does the criteria for prediction of the presence of difficult airways.

Current practice of German anesthesiologists in airway management

Background There is a worldwide consensus among experts that guidelines and algorithms on airway management contribute to improved patient safety in anesthesia. The present study aimed to determine the current practice of airway management of German anesthesiologists and assess the safety gap, defined as the difference between observed and recommended practice, amongst these practitioners. Objective To determine the effect of implementing the guidelines on airway management practice in Germany amongst anesthesiologists and identify potential safety gaps. Methods A survey was conducted in September 2019 by contacting all registered members of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) via email. The participants were asked about their personal and institutional background, adherence to recommendations of the current German S1 guidelines and availability of airway devices. Results A total of 1862 DGAI members completed the questionnaire (response rate 17%). The main outcome was that anesthesiologists mostly adhered to the guidelines, yet certain recommendations, particularly pertaining to specifics of preoxygenation and training, showed a safety gap. More than 90% of participants had a video laryngoscope and half had performed more than 25 awake intubations using a flexible endoscope; however, only 81% had a video laryngoscope with a hyperangulated blade. An estimated 16% of all intubations were performed with a video laryngoscope, and 1 in 4 participants had performed awake intubation with it. Nearly all participants had cared for patients with suspected difficult airways. Half of the participants had already faced a “cannot intubate, cannot oxygenate” (CICO) situation and one in five had to perform an emergency front of neck access (eFONA) at least once. In this case, almost two thirds used puncture-based techniques and one third scalpel-based techniques. Conclusion Current practice of airway management showed overall adherence to the current German guidelines on airway management, yet certain areas need to be improved.

A comfortable and unconscious intubation by the combination of intermittent sevoflurane inhalation and the modified spray-as-you-go technique for a patient with severe postburn mentosternal contracture

Airway management of patients with difficult airways is a challenge to the anesthesiologists and awake tracheal intubation is the recommended strategy. A safe, comfortable, unconscious, and satisfied intubation with spontaneous breathing keeping was achieved by intermittent sevoflurane inhalation and the modified spray-as-you-go technique for airway topicalization and intubation.