Nasotracheal intubation of a patient with restricted mouth opening using a McGrath MAC X-Blade and Magill forceps

Cuff inflation technique is better than Magill forceps technique to facilitate nasotracheal intubation guiding by GlideScope® video laryngoscope

Video laryngoscopy is often selected to assist nasotracheal intubation in allowing better laryngeal visualization, although there is no comparative study evaluating the effectiveness between auxiliary techniques by using Magill forceps and inflated cuff in GlideScope video laryngoscopy for nasotracheal intubation. Fifty-one of 100 patients in a Magill forceps group and 47 of 100 patients in a cuff inflation group were included in the final analysis in this randomized, single-blind, parallel, clinical trial study. Induction agents were routinely administered according to body weight, while intubation time spent, attempts, and related side effects were recorded. Compared to the Magill forceps group, the cuff inflation technique shortened the total intubation time (70.0 ± 24.5 s vs. 87.0 ± 25.0 s, p = 0.001) and the time of advancing the nasotracheal tube from oropharyngeal space into the trachea (25.9 ± 16.4 s vs. 42.3 ± 21.2 s, p < 0.001). However, the number of intubation attempts was not significantly different between groups. During tube advancement, the tube was rotated to accommodate the glottis and trachea more frequently in the cuff inflation group (p = 0.009), but the blade of the laryngoscope shifted and was adjusted to the proper position more frequently in the Magill forceps group (p < 0.001). In the Magill forceps group, the tube cuff might be clipped incidentally and the intubator might shift their gaze away from the screen during intubation, although there was no significant difference in intubation-related side effects between groups. Unlike the conventional approach, nasotracheal intubation with the GlideScope® video laryngoscope using the auxiliary technique of cuff inflation could be more suited than using Magill forceps.

Comparing the first-attempt tracheal intubation success of the hyperangulated McGrath® X-blade vs the Macintosh-type CMAC videolaryngoscope in patients with cervical immobilization: a two-centre randomized controlled trial

We compared the hyperangulated McGrath X-blade with the Macintosh-type CMAC videolaryngoscope through the use of manual in-line stabilization on patients. The primary hypothesis was that the McGrath X-blade has a similar first-attempt success rate as the CMAC videolaryngoscope. 210 patients of ASA physical status I to III, aged 21 to 80 years old, undergoing general anesthesia requiring tracheal intubation were prospectively recruited into this two-centre randomized controlled trial, from June 2016 to April 2019. Patients with history of or predicted difficult airway, pre-existing dental risks, BMI > 35 kg/m², cervical spondylosis or myelopathy, aspiration risks, patients who declined to participate or lacked the mental capacity to give consent were excluded. Participants were intubated using either hyperangulated McGrath X-blade (MGX) or Macintosh-type CMAC (CM) videolaryngoscopy, with manual in-line stabilization. Primary outcome measured was first-attempt tracheal intubation success. Secondary outcomes included overall successful intubation within 2 attempts or 120 s, time to intubation, glottic view obtained and intubation-related complications. First-attempt success rates were 71.4% in the MGX group vs. 79.0% in the CM group (p = 0.26), with an absolute difference of -7.6% (95%CI -20%, 5.0%, p value = 0.26), but this trial was underpowered to detect a difference. Overall success was 91.4% (MGX) vs. 92.4% (CM) (p > 0.99). The Cormack & Lehane laryngeal grade was superior in the MGX group compared to CM group (Grade I: MGX 44%, CM 23%; Grade II: MGX 53%, CM 45%; Grade III: MGX 3%, CM 32%; p < 0.001). The median time to intubation using the MGX was longer than the CM [MGX 55.5 s (42.1-78.3), CM 43.8 s (38-55.3); p < 0.001]. Our study did not demonstrate a significant difference in efficacy between the McGrath X-blade and the CMAC videolaryngoscope. In patients with manual in-line stabilization, no anticipated airway difficulty and in the hands of experienced operators, the McGrath X-blade provided superior glottic views but conferred no advantage over the C-MAC, with a longer median time to intubation compared to the CMAC videolaryngoscope.Trial registration: Australian New Zealand Clinical Trial Registry (ACTRN12616000668404).

Which nostril should be used for nasotracheal intubation with Airtraq NT®: the right or left? A randomized clinical trial

Background/aim

Nasotracheal Airtraq is specifically designed to improve the glottis view and ease the nasotracheal intubation process in normal and difficult cases.

Materials and methods

After Ethics committee approval, we decided to enroll 40 patients with an ASA physical status of I or II, between 18 and 70 years of age undergoing elective maxillofascial, oral, and double chin surgery to determine which nostril is more suitable for nasotracheal intubation with nasotracheal Airtraq. Patients were randomized into the right and left nostril groups.

Results

Demographic and airway characteristics were similar among the groups. Nasotracheal intubation through the right nostril was shorter than that of the left nostril during nasotracheal intubation with the Airtraq NT (P < 0.001). 90° counterclockwise rotation of the tip of the tube was needed for directing the tube into the vocal cords in both right and left nostril groups (72% vs 88%). External laryngeal pressure and head flexion maneuvers can ease the intubation from the left nostril (P < 0.001 vs P = 0.03). Cuff inflation maneuver also can be helpful in some cases. We did not need any operator change or Magill forceps for any of the patients.

Conclusion

Nasotracheal intubation via the right nostril can be safely and quickly performed with the Airtraq NT without the need of Magill forceps. We recommend the use of the 90° counterclockwise rotation, external laryngeal pressure, and head flexion maneuvers to direct the tube into the vocal cords first. On the other hand, cuff inflation maneuver must also be kept in mind.

Videolaryngoscopy versus fiberoptic bronchoscope for awake intubation - a systematic review and meta-analysis of randomized controlled trials

Background

Awake intubation with videolaryngoscopy (VL) is a novel method that is drawing more and more attention as an alternative to awake intubation with fiberoptic bronchoscope (FOB). This meta-analysis is designed to determine the performance of VL compared to the FOB for awake intubation.

Methods

The Cochrane Central Register of Controlled Trials, PubMed, Embase, and Web of science were searched from database inception until October 30, 2017. Randomized controlled trials comparing VL and FOB for awake intubation were selected. The primary outcome was the overall success rate. Rev-Man 5.3 software was used to perform the pooled analysis and assess the risk of bias for each eligible study. The GRADE system was used to assess the quality of evidence for all outcomes.

Results

Six studies (446 patients) were included in the review for data extraction. Pooled analysis did not show any difference in the overall success rate by using VL and FOB (relative risk [RR], 1.00; P=0.99; high-quality evidence). There was no heterogeneity among studies (I²=0). Subgroup analyses showed no differences between two groups through nasal (RR, 1.00; P=1.00; high-quality evidence) and oral intubations (RR, 1.00; P=0.98; high-quality evidence). The intubation time was shorter by using VL than by using FOB (mean difference, −40.4 seconds; P<0.01; low-quality evidence). There were no differences between groups for other outcomes (P>0.05).

Conclusion

For awake intubation, VL with a shorter intubation time is as effective and safe as FOB. VL may be a useful alternative to FOB.

The Channelled Airtraq® as a Rescue Device Following Failed Expected Difficult Intubation with an Angulated Video Laryngoscope

We herein report two expected difficult intubation cases that failed with an angulated-type video laryngoscope (C-MAC D-blade) and were rescued with a channelled-type Airtraq® device. The common signs and characteristics which indicated difficult ventilation and intubation in these patients were Mallampati 4 (with phonation), mandibular protrusion of B, obstructive sleep apnoea disorder, male gender, and thick neck (>46 cm). We had aids ready in the operating theatre for the anticipated difficult intubation. We first attempted to intubate the trachea in two patients with direct laryngoscopy; as expected, the Cormack-Lehane (CL) grades of the two patients were 4, even cricoid pressure was applied. Second, we attempted to intubate with the angulated-type C-MAC D-blade; the CL grades improved to 2. However, despite tube adjustment manoeuvres and use of a rigid stylet, we were unable to insert the tube into the trachea. Then, we attempted to intubate with a channelled-type Airtraq® device. Consequently, without need for a stylet or use of any manoeuvres, we were able to intubate the tracheas at the first attempt.

Videolaryngoscopy versus direct laryngoscopy for nasotracheal intubation: A systematic review and meta-analysis of randomised controlled trials

STUDY OBJECTIVE

Nasotracheal intubation (NTI) is a common practice in the oral and maxillofacial surgeries. A systematic review and meta-analysis was performed to determine whether videolaryngoscopy (VL) compared with direct laryngoscopy (DL) can lead to better outcomes for NTI in adult surgical patients.

MEASUREMENTS

Only randomised controlled trials comparing VL and DL for NTI were included. The primary outcome was overall success rate and the second outcomes were first-attempt success rate, intubation time, rate of Cormack and Lehane classification 1, rate of Magill Forceps used, rate of postoperative sore throat, and ease of intubation.

MAIN RESULTS

Fourteen studies with 20 comparisons (n = 1052) were included in quantitative synthesis. The overall success rate was similar between two groups (RR, 1.03; p = 0.14; moderate-quality evidence). VL was associated with a higher first-attempt success rate (RR 1.09; p = 0.04; low-quality evidence), a shorten intubation time (MD-6.72 s; p = 0.0001; low-quality evidence), a higher rate of Cormack and Lehane classification 1 (RR, 2.11; p < 0.01; high-quality evidence), a less use of the Magill forceps (RR, 0.11; p < 0.01; high-quality evidence) and a lower incidence of postoperative sore throat (RR, 0.50; p = 0.03; high-quality evidence). Subgroup analysis based on whether with a difficult airway showed higher overall success (p < 0.01) and first-attempt success rates with VL (p = 0.04) in patients with difficult airways; however, these benefits was not shown in patients with a normal airway (p > 0.05); Subgroup analysis based on operators' experience showed that success rate did not differ between groups (p > 0.05), but intubation time was shortened by more than 50s by non-experienced operators (p < 0.05). Subgroup analysis based on different devices used showed that only non-integrated VL led to a shorter intubation time (p < 0.05).

CONCLUSIONS

The use of VL does not increase the overall success rate of NTI in adult patients with general anesthesia, but it improves the first-attempt success rate and laryngeal visualization, and shortens the intubation time. VL is particularly beneficial for patients with difficult airways.

Flexible laryngeal mask airway management for dental treatment cases associated with difficult intubation

Nasotracheal intubation is generally a useful maxillofacial surgery that provides good surgical access for intraoral procedures. When nasotracheal intubation is difficult, laryngeal mask airway (LMA) insertion can be performed, and the flexible LMA™ (FLMA) is also useful for anesthetic management. However, the FLMA provides limited access to the mouth, which restricts the insertion of instrumentation and confines the surgical field available. Here, we present our experience using the FLMA airway management for dental treatment cases involving difficulty with intubation.