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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