Oral and nasotracheal light wand guided intubation after failed fibreoptic bronchoscopy

Does Increasing the Bend Angle of a Stylet to 90° Increase the Nasotracheal Intubation Success Rate?

BACKGROUND

Video-stylet-guided nasotracheal intubation (NTI) is an effective technique for airway management. However, the impact of the bend angle on the success rate of intubation remains unclear.

PURPOSE

Does increasing the bend angle of a stylet to 90° increase NTI success rate?.

STUDY DESIGN, SETTING, SAMPLE

This prospective randomized controlled trial was conducted in the operating room of a population-based hospital. Adult patients requiring NTI were recruited.

PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE

The primary predictor variable is the choice of stylet bend angle (90° vs 70° bend) in NTI.

MAIN OUTCOME VARIABLE(S)

The primary outcome variables were success rates of NTI, defined as the proportion of successful intubation cases to total cases.

COVARIATES

Demographics, intubation time, the distance from the thyroid prominence to the nostril, additional maneuvers applied during intubation, and cases of epistaxis were recorded.

ANALYSES

The student's t-test was used to compare continuous variables between groups. Ordinal data (intubation attempts, head extension, and epistaxis) were analyzed using the Wilcoxon rank-sum test. As appropriate, frequency (external pharyngeal pressure) was analyzed using the χ2 test or Fisher's exact test. A P value of <.05 was considered statistically significant.

RESULTS

Of the 103 subjects assessed for eligibility, 98 were enrolled in the study. The mean age (27.0 ± 6.9 years vs 27.0 ± 4.1 years, P = .972) and sex differences (male/female: 9/40 vs 7/42, P = .136) were comparable between groups. The overall success rate in the 70° group was significantly lower than that in the 90° group (91.8 vs 100%, P < .001). The intubation time in the 70° group was significantly longer than that in the 90° group (43.2 ± 15.8 s vs 33.7 ± 7.3 s, P < .001).

CONCLUSIONS AND RELEVANCE

A 90° bend angle of the stylet significantly improves the likelihood of successful NTI.

Relevance of radiological and clinical measurements in predicting difficult intubation using light wand (Surch-lite™) in adult patients

Objective

To determine the correlation between anatomical features of the upper airway (evaluated via computed tomography imaging) and the ease of light wand-assisted endotracheal intubation in patients undergoing ear, nose and throat surgery under general anaesthesia.

Methods

Mallampati class, laryngoscopic grade, thyromental distance, neck circumference, body mass index, mouth opening and upper lip bite class were assessed. Epiglottis length and angle, tongue size and narrowest pharyngeal distance were determined using computed tomography imaging. Intubation success rate, time to successful intubation (intubating time) and postoperative throat symptoms were documented.

Results

Of 152 patients, 148 (97.4%) were successfully intubated on the first attempt (mean intubating time 11.5 ± 6.7 s). Intubating time was positively correlated with laryngoscopic grade and body mass index in both male and female patients, and Mallampati class and neck circumference in male patients. Epiglottis length was positively correlated with intubating time.

Conclusions

Ease of intubation was influenced by epiglottis length. Radiological evaluation may be useful for preoperative assessment of patients undergoing endotracheal intubation with light wand.

S. Pediatric Otolaryngology

Otolaryngologic procedures are commonly performed on children. In fact, pressure equalizing tube placement (ear tubes) and adenotonsillectomy are among the most frequent surgical interventions in the pediatric population. Therefore, every anesthesiologist who manages children undergoing otolaryngologic procedures must be familiar with the special implications of sharing the pediatric airway with an otolaryngologist working in the head and neck region. In addition, it is imperative to be skilled in the challenges of compassionately yet safely managing anxious young patients and their parents from the time of preoperative assessment until discharge from the post anesthesia care unit.

Temporomandibular joint interpositional gap arthroplasty under intravenous (I.V) conscious sedation

Ankylosis may be defined as the fusion of joint surfaces. Temporomandibular joint (TMJ) ankylosis is a condition that may cause chewing, digestion, speech, esthetic and psychological disorders. It is a devastating disorder resulting in inability to open the mouth. As a result of this, General anaesthesia, is very difficult to administer because laryngeal inlet is not directly visualized. Even the blind nasal intubation is difficult because of small mandible and tongue fall following relaxation. There are various techniques to overcome these challenges. At times these techniques fail and tracheostomy has to be done. All the risks associated with difficult intubation, and general anaesthesia can be avoided if the surgery is done under conscious sedation. Conscious sedation, a simple but safe and effective method of anaesthesia is described here, which allows successful temporomandibular joint interpositional gap arthroplasty.

Surgery of temporomandibular joint under local anaesthesia

Temporomandibular joint ankylosis is a debilitating disorder arising from an inability to open the mouth. This leads to poor nutrition, poor dental hygiene, and stunted growth. Anaesthesia, especially general anaesthesia, is very difficult to administer. There is a lack of direct visualization of the vocal cords, tongue fall following relaxation, and an already narrowed passage due to a small mandible, which makes even the blind nasal intubation difficult. There are various techniques described in literature to overcome these challenges, failing which, one needs to do tracheostomy. All the risks of difficult intubation and general anaesthesia can be avoided if the surgery is done under local anaesthesia. A simple but effective method of successful local anaesthesia is described, which allows successful temporomandibular joint reconstruction.

The Shikani Seeing Stylet for difficult intubation in children: initial experience

The Shikani Seeing Stylet is a recently introduced reusable intubating stylet, produced in adult and paediatric versions. It combines features of a fibreoptic bronchoscope and a lightwand. Inside a malleable stainless steel sheath, the Shikani Seeing Stylet has a fibreoptic cable leading to a distal light source and high-resolution lens. In use, the stylet is placed in the lumen of the selected endotracheal tube and the light source enables the stylet to be used as a lightwand, while the fibreoptic capability enables visualization of the laryngeal inlet. It is portable, relatively inexpensive and easy to maintain. This report describes the use of the stylet on eight occasions in seven children, all of whom were assessed preoperatively as being potentially difficult to intubate. Three had been difficult to intubate previously. All were anaesthetized using inhalational anaesthesia. Once an adequate depth of anaesthesia had been achieved, conventional direct laryngoscopy was performed and identified as Grade 3 in six of the patients and Grade 1 in one. Tracheal intubation was then attempted using the Shikani Seeing Stylet. On six of the eight occasions the attempt was made by different anaesthetists, none of whom had any prior clinical experience with the stylet. There were seven successful intubations and one failure in a patient who could not be intubated by any method. The Shikani Seeing Stylet seems a useful device for use in children with difficult airway problems, suspected cervical spine instability or limited mouth-opening.

Tracheal intubation in children with Morquio syndrome using the angulated video-intubation laryngoscope

PURPOSE

There are a number of syndromes with proven or suspected instability of the cervical spine especially in pediatric patients. It is a challenge for the anesthesiologist to intubate these patients with as little movement of the cervical spine as possible. A new device to facilitate this task is the angulated video-intubation laryngoscope (AVIL).

CLINICAL FEATURES

The AVIL is a curved endoscopic intubation laryngoscope with angulated distal tip. The video-view from the distal blade tip improves glottic visualization during difficult direct laryngoscopy. We report three sisters with Morquio syndrome scheduled for otorhinolaryngology surgery the same day. Two of them had radiologically suspected cervical spine instability. Tracheal intubation was planned with careful direct laryngoscopy under manual in-line stabilization of the neck and head by an assistant. Direct visualization of the larynx using a Miller blade No. 2 was impaired in two of the three children in whom the cervical spine was immobilized. They were both successfully intubated under endoscopic control using the AVIL.

CONCLUSION

The AVIL may become a helpful device to aid endotracheal intubation in patients when cervical spine immobilization impairs direct laryngoscopy.