Airway management data show

Airway Management: A Comparative Study

Using McGrath® Video laryngoscope versus

Airtraq® and Macintosh Laryngoscope in Neutral Position.

Presented byAlaa Elsayed Goma Falogy

M.Sc. Assistant lecturer of Anaesthesia and Surgical Intensive care

Faculty of medicineZagazig University

Under supervision of Prof. Dr. Ayman Abdel El-

Salam HassanProfessor of Anesthesia and surgical

Intensive Care

Prof. Dr. Ahmed Abd El-Hakim Balata

Professor of Anesthesia and surgical Intensive Care

Prof. Dr. Khaled Mohammed

El-Sayed Professor of Anesthesia and surgical

Intensive Care

I would like to thank….

Prof, Dr.: Salah A. Fattah Ismail

For his sincere effort to travel all this distance to give us this honor to be with us this special day

I would like to thank….

Prof, Dr.: Ahmed M. Salama

For his pleased acceptance to share us this discussion

I would like to thank….

to my precious family;you mean the world to meyou'll always be my strength, my power, thank you for being a part of me...

Research questionIfused by [experienced anesthiologists] who is managing a model of a difficult airway in form of neck immobilization by semi- rigid neck collarDo [ the Airtraq OL and the McGrath VL] Are more safe and more effective in tracheal intubation when compared to [Classic Macintosh laryngoscope]?

Introduction

• Airway management is a major challenge for the anaesthesiologists in their everyday operative practice using direct laryngoscopy.

• During this direct laryngoscopy, positioning of the head and neck in neutral position

• will decrease chance of optimal laryngeal visualization which impair the line of sight between laryngeal , pharyngeal and oral axes.

Concept of line of sight during direct laryngoscopy

• patients with cervical spine instability who necessitate neck immobilization , airway management implies upon a high risk of neurological damage related to head and neck manipulation, so semi-rigid neck collar is applied in trail to control neck movement.

• Such immobilisation technique can turn intubation process under the direct laryngoscopy into more difficult situation (Impair the line of sight) .

• These concerns have aroused the idea to develop number of alternatives to classical Macintosh laryngoscope such as Airtraq® Optical Laryngoscope, McGrath® Video laryngoscope.

• These laryngoscopes do not require the arrangement of pharyngeal, laryngeal and oral axis in one line of sight and thus do not require modulation of neutral position.

• During difficult airway situations, both Airtraq optical laryngoscope and McGrath Video laryngoscope sound to be better than Macintosh laryngoscope

AIM OF THE WORK To evaluate the efficacy and safety of

in stimulated difficult intubation situations in patients with their cervical spine kept in

neutral position by semi-rigid neck collar as an

immobilization techniques .

VS

Neck extension During intubation may badly affects the cervical instability and this is may imply upon risk of spinal cord injury

NECK EXTENSION

Cervical spine stability Cervical stability: is the ability of the

spine to maintain strong relationships between vertebrae, so as not to damage the neural structures contained within the spinal column

Cervical instability: Excess translational

or rotational motion of any vertebra and means that the odontoid process is no longer firmly held against the back of the anterior arch of C1.

Concept of Videolaryngoscopy Video laryngoscopy (VL) is an

update of high resolution micro-cameras systems that improves the success rate of intubation.

There is a hypothesis that improved lighting and a better view can increase the chance of intubation success.

Anaesthesia had used the miniature camera for many years but for only bronchial endoscopy .

Video Laryngoscopy in difficult Airway management

VIDEO ASSISTED LARYNGOSCOPY

AS AN INTIAL APPROACH TO

INTUBATION

McGrath Video-Laryngoscope

The McGrath Video Laryngoscope:

(Aircraft Medical, Edinburgh, United Kingdom) • A video-based system for tracheal

intubation that utilizes a video camera embedded into a camera stick.

• The unit is a battery powered Features a single electronic control

• Offers the user an image of the Glottis and the surrounding anatomy on a LCD screen.

• The unit which is used as a part of much the same way as common as Macintosh laryngoscope

Concept of the improved glottic view

Based upon the hypothesis that improved glottic view leads the better chance of successful intubation

Airtraq Optical-

Laryngoscope

based on refraction prism principle to give an angular view of the glottic area.

The blade of the Airtraq consists of two side by side channels.

One channel act as housing for the ETT, and the other channel terminates in terminal lenses and transmit back the image.

The viewed image is then been transmitted to a proximal eye piece viewfinder employing a prisms system and lenses not as basic concepts of usual fiberoptics.

AIRTRAQ Optical Laryngoscope:

PATIENTS AND

METHODS

METHODOLOGY This was a prospective, randomized

clinical trial. group assignments (C, A and M) age group of 20-50 years, ASAps

Grades I or II undergoing elective surgery requiring general Anaesthesia

three groups of 50 patients each , of either sex.

All patients received standard monitoring according to ASA guidelines.

INTUBATION PROCEDURE

Intubation process was performed by one anesthesiologist with accepted experience in two recent video laryngoscopes under study.

A malleable stylet was used in both groups (Classical Macintosh and McGrath VL).

The technique was considered failed if tracheal intubation was not achieved within 120 seconds or within a maximum of three intubation attempts.

CORMACK - LEHANE SCORE

INTUBATION PROCEDURE

Intubation time was separated into T1 and T2.

T1 is the time between insertions of the allocated laryngoscope in the mouth until optimal glottic view including optimization maneuvers.

T2 is the time from optimal glottic view till confirmation of tracheal intubation (by vision) including removal of the device.

McGrath VL;INTUBATION TECHNIQUE

AND SEQUENCE

Intubation sequence by McGrath VL

With the patient in neutral position, use left hand to introduce the VL into the midline of the oropharynx.

Push the blade tip till it past the posterior portion of the tongue.

Then turn eyes to the video screen in order to obtain the best view of the glottis.

The video image of the glottis now is representing Cormack – Lehane view.

Using LCD screen, the ETT is then advanced on a smooth curve through the glottis mediated by stylet.

Intubation sequence by McGrath VL

introduce the VL into the midline of mouth and Push the blade tip till posterior portion of the tongue.

Intubation sequence by McGrath VL

turn eyes to the video screen in order to obtain the best Cormack – Lehane view.

Intubation sequence by McGrath VL

By use of LCD screen, the ETT is then advanced on a smooth curve through the glottis by stylet.

AIRTRAQ OL;INTUBATION TECHNIQUE

AND SEQUENCE

Intubation sequence by Airtraq OL

Add lubricant to outer surface of the endotracheal tube and hosting channel of Airtraq OL.

Embed the tube into the side holding channel of the Airtraq so that the tip of the endotracheal tube is at the tip of the side channel.

Turn on the light for about 30-60 seconds before the procedure.

Intubation sequence by Airtraq OL

The device is held in the mouth in the midline by right hand .

Then advanced by sliding over the tongue.

The image on view finder is optimized by moving the blade as necessary by left hand.

The laryngeal inlet must be in the centre of viewfinder just before pushing the ETT forward by right hand .

Intubation sequence by Airtraq OL

Loading ETT to hosting channel

Introduction into oral cavity

Intubation sequence by Airtraq OL

Sliding over the tongue

Checking the viewfinder and ETT insertion

Intubation sequence by Airtraq OL

Unholding the ETT from the

Airtraq Removal of the Airtraq

RESULTS

PARAMETERS TO BE COMPARED BETWEEN ALL

GROUPS Demographic data and Airway assessment data. Intubation Conditions:

Numbers of Attempts. Optimization Procedures. Cormack - Lehane score. Intubation Difficulty Score.

Success Rate of Intubation. Time To Intubation. Hemodynamics (HR and MAP). Complications.

DEMOGRAPHIC AND AIRWAY ASSESSMENT

DATADemographic data Group C Group A Group M

p-value (Sig.) (N=50) (N=50) (N=50)

Age (in years) 35.90±7.65 35.92±7.70 35.16±7.72 0.856** (NS)

Male / Female 62 / 38 % 66 / 34 % 60 / 40 % 0.892* (NS)

Height (cm) 171.48±3.71 171.62±3.54 171.6±3.8 0.981** (NS)

Weight (Kg) 77.96±7.22 77.62±6.25 76.86±6.93 0.619** (NS)

BMI (Kg/m2) 26.84±2.29 27.06±2.05 26.14±2.13 0.095** (NS)

ASAps I / II 14 / 86 % 16 / 84 % 10/ 90 % 0.668* (NS)

MS I / II 56 / 44 % 48 / 52 % 62 / 38 % 0.369* (NS) TMD (cm) 7.18±0.34 7.12±0.34 7.17±0.32 0.766** (NS)

NON-SIGNIFICA

NT

NUMBERS OF ATTEMPTS

Macintosh group

Airtraq group

McGrath group

Most of patients in VL need 1 attempt for successful intubation

About 1/3 patients needed 2nd and 3rd attempt in Macintosh group

HS

OPTIMIZATION PROCEDURE

Highly Significant

CORMACK-LEHANE SCORE

46

Airtraq almost get C&L I

Mac

into

sh le

ast i

n C

&LI

PER

SIS

T

Most views of McGrath C&L II

Macintosh most C&L II

HIGHLY- SIGNIFICANT

IDS DISTRIBUTION

Airt

raq

max

IDS

is 2

McG

rath

max

IDS

is

4

Mac

into

sh r

each

ed

IDS

7

HIGHLY- SIGNIFICAN

T

SUCCESS RATE OF INTUBATION

Mac

into

sh h

as 4

fa

ilure

s

NON-SIGNIFICAN

T

SAFETY AND EFFECTIVENESS

INTER-GROUP ANALYSIS

49

BETTER IMAGE

CONCEPT THOERY SA

ME

VID

EOSC

OPE

EF

FIEN

CY

FAMILARITY

NO NEED FOR

ALIGNMENT

AIRTRAQ LEAST

MACINTOSH MOST

HEMODYNAMICS (HR)

NO

N-

SIG

NIF

ICAN

T

HS

HIG

H

SIG

NIF

ICAN

T

HIG

H S

IGN

IFIC

ANT

ALL Increased MAP

ALL return to basal level

HEMODYNAMICS (MAP)

NO

N-

SIG

NIF

ICAN

T

Time to Intubation

52

Familiarity and same technique

HIG

H

SIG

NIF

ICAN

T

3 2 1 3 1 2

Complications

Sharp tip for both devices produce

more trauma

as primary insult more than

secondary injury

Styl

et

man

ipul

atio

n??

Primary > secondary

Secondary is more than primary

LIMITATIONS DESIGN

Operator knows the devices, which may also introduce bias. (solved by closed envelopes

basis (lottery technique)). STIMULATIVE

Not on real cervical trauma patients. FURTHERMORE,

Inter-incisor distance may be added in airway assessment parameters as pre and post

insertion of neck collar especially because it affects primary insertion of Airtraq OL.

SUMMARY AND

CONCLUSION

Research questionAre McGrath® Video laryngoscope versus

Airtraq more safe and more effective in

tracheal intubation when compared to Classic Macintosh laryngoscope in

patients with neck collar inserted?

Yes

Airtraq OL and McGrath VL showed the prove beyond doubt to be safer and more effective than Macintosh Laryngoscope in managing stimulated difficult intubation situation in form of cervical spine immobilization.

RECOMMENDATIONS

The use of videolaryngoscopes in our daily practice is recommended specially in difficult airway scenarios and similar studies need to be done upon real cervical trauma patients for better assessment of its advantages and disadvantages.

THANK YOU