A comparison of McGrath and Macintosh laryngoscopes in novice users: a manikin study

Routine Use of Videolaryngoscopy in Airway Management

Tracheal intubation is a fundamental facet of airway management, for which the importance of achieving success at the first attempt is well recognized. Failure to do so can lead to significant morbidity and mortality if there is inadequate patient oxygenation by alternate means. The evidence supporting the benefits of a videolaryngoscope in attaining this objective is now overwhelming (in adults). This has led to its increasing recognition in international airway management guidelines and its promotion from an occasional airway rescue tool to the first-choice device during routine airway management. However, usage in clinical practice does not currently reflect the increased worldwide availability that followed the upsurge in videolaryngoscope purchasing during the coronavirus disease 2019 pandemic. There are a number of obstacles to widespread adoption, including lack of adequate training, fears over de-skilling at direct laryngoscopy, equipment and cleaning costs, and concerns over the environmental impact, among others. It is now clear that in order for patients to benefit maximally from the technology and for airway managers to fully appreciate its role in everyday practice, proper training and education are necessary. Recent research evidence has addressed some existing barriers to default usage, and the emergence of techniques such as awake videolaryngoscopy and video-assisted flexible (bronchoscopic) intubation has also increased the scope of clinical application. Future studies will likely further confirm the superiority of videolaryngoscopy over direct laryngoscopy, therefore, it is incumbent upon all airway managers (and their teams) to gain expertise in videolaryngoscopy and to use it routinely in their everyday practice..

Comparison of AirAngel® vs. Storz® videolaryngoscope and Macintosh® laryngoscope for endotracheal intubation training: prospective randomized crossover study

BACKGROUND

For both normal and difficult airway management, VL is thought to be more effective. However, VL seems far from being offered as a standard option in both healthcare delivery and educational activities in low-income countries, considering its high costs. Therefore, three-dimensional(3D)printed VLs may be considered an alternative to conventional VLs in low-income countries and other places with limited resources. Our objective was to compare the efficacy of AirAngel 3D-printed VL (3D-PVL) with those of commercially available Storz® VL (SVL) and conventional Macintosh® laryngoscope (MCL) in normal and difficult airway scenarios in the hands of inexperienced users.

METHODS

This is a prospective randomized crossover manikin study that included 126 senior medical students with no experience in intubation. The effectiveness of all three laryngoscopy devices in the hands of inexperienced users was evaluated in terms of intubation time, glottic visualization, ease of use, endotracheal tube placement, and intubation success rate. Between 2020 and 2022, 126 last year medical students participated in the study.

RESULTS

MCL resulted in significantly longer intubation times than 3D-PVL and SVL in the difficult airway scenario, with no significant difference between 3DPVL and SVL (Wilcoxon test, p < 0.016; Bonferroni correction MCL: 28.54 s; SVL: 26.68 s; 3DPVL: 26.64 s). Both SVL and 3D-PVL resulted in significantly better Cormack - Lehane grades in both normal and difficult airway scenarios, and thus provided better glottic viewing than MCL, with no significant difference between 3D-PVL and SVL (Wilcoxon test, p < 0.016; Bonferroni correction, MCL: 1.73; SVL: 1.29; 3DPVL: 1.25). The SVL was the easiest device to use for normal airway scenarios (1: very easy, 5: very difficult), while the MCL was the most difficult (MCL: 2.64; 3DPVL: 1.98; SVL: 1.49). Conversely, no significant difference was found between 3DPVL and other devices in terms of ease of use in difficult airway scenarios and in terms of accurate placement of the endotracheal tube and successful intubation attempts.

CONCLUSION

3D-PVL is a good educational and possible clinical alternative to conventional VL, particularly in places with limited resources, due to its low cost.

A comparison of tracheal intubation using intubrite laryngoscope and conventional MAC laryngoscope: An open, prospective, crossover manikin study

BACKGROUND

New devices are more available in the pre-hospital environment operational theaters and emergency departments. One is an intubrite laryngoscope (INT) with Dual LED lighting that combines ultraviolet and white LED. The study aimed to compare the efficacy of endotracheal intubation using INT and conventional laryngoscope performed by inexperienced paramedics (paramedics students) and paramedics with experience in advanced airways management in full and limited accessibility settings.

METHODS

It was an open, prospective, crossover manikin study. Sixty paramedics and paramedic students were recruited. Participants were divided into 2 equal groups depending on their experience (n = 30). Experienced participants were further randomly divided into 2 groups (n = 15). Inexperienced participants were also randomly divided into 2 groups (n = 15). The criterion of inexperience was 5 or fewer intubation by any laryngoscope. Inexperience participants were asked to perform tracheal intubation in standard pre-hospital settings (without limited access to manikin) (scenario A) and difficult pre-hospital settings (limited access to manikin - narrow space between benches) (scenario B). Experience participants were asked to intubate manikin in difficult pre-hospital settings.

RESULTS

In the normal pre-hospital environment, the success rate after the first attempt was 56,7% for conventional laryngoscope and 66,7% for intubrite. However, the overall effectiveness of tracheal intubation using both laryngoscopes in 3 attempts was 90% for both devices. The successful rate of first attempt intubation in a difficult environment by inexperienced was 73,3% for INT and 50% for conventional laryngoscope. Overall effectiveness was 83,3% and 86,7% respectively. The successful rate of first attempt intubation in the experienced group was 86,7% with INT compared to 60% with a conventional laryngoscope in difficult settings. Overall effectiveness was 96,7% for both devices.

CONCLUSION

Intubrite provided better working conditions and make up for deficiencies in successful tracheal intubation by inexperienced participants in a normal and difficult environment. Tracheal intubation with intubrite was more effective in the experienced group. Tracheal intubation effectiveness with intubrite was also higher in the experienced group.

The impact of introducing a videolaryngoscope in the initial training of laryngoscopy for undergraduate medical students: a simulation randomized trial

INTRODUCTION

Adequate and continuous airway management by health professionals is fundamental to ensure patient safety and protection. Among several techniques, laryngoscopy for orotracheal intubation is considered a basic skill, so it is taught and learned in medical school and used during the future years of professional practice. However, in some clinical scenarios, physical and anatomical characteristics can make laryngoscopy exceedingly difficult. In the last decade, some new devices have emerged to apply indirect or video-assisted imaging systems, so-called videolaryngoscopes. They have shown great efficiency in difficult intubation cases and have improved teaching and training. Our study introduced a videolaryngoscope, the McGrath... MAC, in the regular laryngoscopy training rotation for 3rd-year undergraduate medical students and evaluated whether there was any associated optimization of the students...

PERFORMANCE

METHOD

Students from two different classes and years (2017 and 2018) were randomly divided into two groups and received theoretical and practical training in the techniques of Direct Laryngoscopy (DL) and Videolaryngoscopy (VL). The students in each group applied the manoeuvres and simulated three tracheal intubation attempts on mannequins. They were evaluated for their success rate on the first attempt, the time required to finalize the intubation, and the visualization of the glottic structures according to the classification of Cormack-Lehane (C&L).

RESULTS

Two hundred and four students with an average age of 21.ß...ß2 years participated in the study; the groups were similar. There was a significant difference between the VL and DL groups in the 1st attempt success rate (97% and 89.4%, respectively, p.ß=.ß0.0497 ... 95% CI), but such a difference was not seen for the other attempts or regarding the number of oesophageal intubations (3% and 7.7%). The students in the VL group were faster than those in the DL group in all intubation attempts; in parallel, the vast majority of the VL group reported excellent visualization conditions, with 75% of the attempts classified as Cormack-Lehane grade 1.

CONCLUSION

The introduction of a videolaryngoscope in medical students... training improved the visualization of anatomical structures and allowed tracheal intubation maneuvers to be performed faster and with a higher success rate on the first attempt. Thus, under the conditions of this prospective study, the videolaryngoscope had a positive impact on training and proved to be a promising tool for teaching laryngoscopy.

Implementation of video laryngoscopes and the development in airway management strategy and prevalence of difficult tracheal intubation: A national cohort study

BACKGROUND

We aimed to determine the development in the use of video laryngoscopy over a 9-year period, and its possible impact on airway planning and management.

METHODS

We retrieved 822,259 records of tracheal intubations recorded from 2008 to 2016 in the Danish Anaesthesia Database. The circumstances regarding pre-operative airway assessment, the scheduled airway management plan and the actual airway management concerning video laryngoscopy were reported for each year of observation. Further, the association between year of observation and various airway management related outcomes was evaluated by multivariate logistic regression.

RESULTS

There was a significant increase in airway management with 'advanced technique successfully used within two attempts' from 2.7% in 2008 to 15.5% in 2016 (p < .0001). This predominantly reflects use of video laryngoscopy. The prevalence of tracheal intubations 'scheduled for video laryngoscopy' increased from 3.5% in 2008 to 10.6% in 2016 (p < .0001). We found a significant increase in the prevalence of anticipated difficulties with intubations by direct laryngoscopy from 1.8% in 2008 to 5.2% in 2016 (p < .0001). The prevalence of failed tracheal intubations decreased from 0.14% in 2008 to 0.05% in 2016 (p < .0001).

CONCLUSION

From 2008 to 2016, a period of massive implementation of video laryngoscopes, a significant change in airway management behaviour was recorded. Increasingly, video laryngoscopy is becoming a first-choice device for both acute and routine airway management. Most importantly, the data showed a noticeable reduction in failed intubation over the time of observation.

Video Versus Direct Laryngoscopy in Novice Intubators: A Systematic Review and Meta-Analysis

Video laryngoscopy (VL) is increasingly used in airway management and has been shown to decrease the rate of failed intubation in certain clinical scenarios, such as difficult airways. Training novices in intubation techniques requires them to practice on living patients; however, this is less than ideal from a safety perspective given the increased risk of complications after multiple attempts or failed intubation by inexperienced trainees. One setting in which VL may be beneficial is in training, although whether these devices should be used among novices instead of direct laryngoscopy (DL) remains unclear. The purpose of this systematic review and meta-analysis is to compare the outcomes of VL and DL when used by novices to perform intubation in the operating room. The secondary aims are to correlate outcomes with different types of VLs and with different types of novices, such as medical students, residents, and non-anesthesiology trainees. Databases were searched for studies that compared the outcomes of VL versus DL in endotracheal intubation performed by novices on patients with expected normal airways and no history of difficult intubation or cervical spine instability undergoing general anesthesia in the operating room. The primary outcome was the initial success rate. The secondary outcomes were time to intubate and the number of unintended esophageal intubations. A meta-analysis was performed to determine the difference, if any, in outcomes between VL and DL. Sub-analyses were also performed after the stratification of data by the type of VL used and the type of novice. Ten studies were included with 1,730 intubations. Studies varied by VL type and novice type. The overall results from the meta-analysis demonstrated an increased success rate and decreased time to intubate with VL compared to DL. Four studies showed a reduction in esophageal intubation with VL compared to DL. Sub-analysis by VL type showed that improved outcomes with VL over DL were maintained only with the use of channeled VLs rather than non-channeled VLs. Sub-analysis by novice type showed that improved success rates with VL over DL were maintained only among medical students. Novices may have a higher initial success rate and faster intubation time when using a channeled VL compared to DL. Medical students also show improved success rates when using VL rather than DL, while residents and other types of novices do not. These findings may help guide clinicians in determining the most effective devices to use when teaching airway management while also maintaining the highest possible level of patient safety.

Which Device Is Favorable for Intubation Attempts of Pediatric Residents on Four Different Pediatric Airway Simulations?

OBJECTIVES

Endotracheal intubation is an essential skill for the pediatric airway management. Although direct laryngoscopy (DL) is the standard method, several videolaryngoscopes (VLs) have been recently enhanced as an alternative especially for difficult intubations. We aimed to compare McGrath MAC (McG) and Storz C-MAC PM (ST) VLs with DL in terms of intubation success rate, time to intubation (TTI), and duration of obtaining glottis view of intubation attempts performed by pediatric residents on different pediatric airway manikins.

METHODS

The pediatric residents with no experience in videolaryngoscopy were included. After a brief demonstration, intubation attempts with 3 randomly handled different devices with 6 different blades were performed on a child manikin, an infant manikin, a Pierre-Robin sequence infant manikin, and a child manikin with cervical immobilization sequentially.

RESULTS

Fifty pediatric residents were enrolled. The attempts of DL on child manikin and attempts of all devices on child with cervical immobilization simulation were completely successful. For the attempts on both infant manikin and Pierre-Robin sequence infant manikin, the success rate of McG was significantly lower than ST and DL (P = 0.011 and P = 0.001). In the child manikin, McG and ST had prolonged TTI compared with DL (P = 0.016 and P = 0.001). For the child with cervical immobilization simulation, TTI of DL was significantly shorter than McG and ST (P = 0.011 and P = 0.001). Time to intubation of McG was significantly longer than DL and ST for the attempts on both 2 infant manikins. The rate of Cormack-Lehane grade I glottis view was similar for the attempts on both 2 child airway simulations. For infant manikin and Pierre-Robin sequence infant simulation, the rate of Cormack-Lehane grade I of ST was higher than attempts of DL and McG.

CONCLUSIONS

The attempts of pediatric residents on infant normal airway and Pierre-Robin sequence infant airway simulations resulted with enhanced glottis view by the utilization of Storz C-MAC PM, but both 2 VLs did not provide the improvement of intubation success rate and TTI compared with DL on these 4 different pediatric manikins. Further clinical studies of different VLs in different clinical courses are required for a reliable utilization in children.

Comparison of a New Video Intubation Stylet and McGrath® MAC Video Laryngoscope for Intubation in an Airway Manikin with Normal Airway and Cervical Spine Immobilization Scenarios by Novice Personnel: A Randomized Crossover Study

The use of both a video laryngoscope and a video intubation stylet, compared with the use of a direct laryngoscope, is not only easier to learn but also associated with a higher success rate in performing endotracheal intubation for novice users. However, data comparing the two video devices used by novice personnel are rarely found in literature. Nondelayed intubation is an important condition to determine the prognosis in critically ill patients; hence, exploring intubation performance in various situations is of clinical significance. This study is aimed at comparing a video stylet and a video laryngoscope for intubation in an airway manikin with normal airway and cervical spine immobilization scenarios by novice personnel. We compared the performance of intubation by novices between the Aram Video Stylet and the McGrath® MAC video laryngoscope in an airway manikin. Thirty medical doctors with minimal experience of endotracheal intubation attempted intubation on a manikin five times with each device in each setting (normal airway and cervical spine immobilization scenarios). The order of use of the devices in each scenario was randomized for each participant. In the normal airway scenario, the Aram stylet showed a significantly higher rate of successful intubation than the McGrath® (98.7% vs. 92.0%; odds ratio (95% CI): 6.4 (1.4–29.3); p = 0.006). The intubation time was shorter using the Aram Stylet than that using the McGrath® video laryngoscope (p < 0.001). In the cervical immobilization scenario, successful endotracheal intubation was also more frequent using the Aram stylet than with the McGrath® (96.0% vs. 87.3%; odds ratio (95% CI): 3.5 (1.3–9.0); p = 0.007). The Aram Stylet intubation time was shorter (p < 0.001). In novice personnel, endotracheal intubation appears to be more successful and faster using the Aram Video Stylet than the McGrath® MAC video laryngoscope.

Comparison of direct laryngoscopy and video-assisted laryngoscopy in pediatric intensive care unit

Our objective was to compare video-assisted laryngoscopy (VAL) with direct laryngoscopy (DL) for glottic visualization in a pediatric intensive care unit in terms of the success rate in first attempts. Our study included patients aged from 1 month to 18 years who were admitted to the pediatric intensive care unit. We excluded patients with limited neck extension (C-spine immobilization, congenital abnormality), congenital anomalies (e.g., Pierre Robin syndrome, micrognathia, macroglossia), and recent airway surgery. Patients were premedicated before intubation. The time to intubation was defined as the time between the start of anesthesia and completion of intubation. The start of anesthetic induction was defined as the time the sedative was first administered. Completion of intubation was defined as the time that the end-tidal carbon dioxide tension was detected. We evaluated 120 of 135 intubations that met our inclusion criteria; 15 were excluded because in eight cases (53%) non-pediatric intensive care physicians made the initial attempts, and in seven cases (47%) the recorded intubation times were erroneous. We detected significantly higher POGO scores in the VAL group (p<0.001). VAL provided a fuller view of the glottis (Cormack and Lehane grade 1) than DL (p<0.001). Although the intubation attempts in the DL group were significantly higher (two or more attempts), no intubation failures occurred in either group.

A Comparative Study in Airway Novices Using King Vision Videolaryngoscope and Conventional Macintosh Direct Laryngoscope for Endotracheal Intubation

Background and Objectives

Tracheal intubation using laryngoscopy is a fundamental skill, for an anesthesiologist. However, teaching this skill is difficult since Macintosh direct laryngoscope (DL) allows only one individual to view the larynx during the procedure. Hence, this study aimed to determine whether King Vision® videolaryngoscope (KVL) provides any advantage over direct laryngoscopy in teaching this skill to airway novices.

Materials and Methods

In this prospective randomized crossover study, Ethical Committee clearance was obtained from the institutional review board (MSRMC/EC/2017) and the study was registered with Clinical Trial Registry. After informed consent, 53 medical students were allotted to perform laryngoscopy and endotracheal intubation on a manikin by using either KVL or Macintosh DL. The participants first performed laryngoscopy with either KVL or Macintosh DL following a brief instruction and then crossed over to the second arm of the study to perform laryngoscopy using the other scope. The primary outcome measure was the time for successful endotracheal intubation. The secondary outcome measures were incidence of esophageal intubation (EI), excess application of pressure on maxillary teeth excess maxillary pressure, and success rate.

Results

Mean time for endotracheal intubation was significantly faster using KVL than in DL (44.64 vs. 87.72 s; P < 0.001). No significant difference was found in the incidence of esophageal intubation 15.1% in KVL group versus 24.5% in DL group (P = 0.223). In the KVL group, 81.1% did not apply pressure on maxillary teeth versus 26.4% in the DL group (P < 0.001). The success rate of intubation was 100% in the KVL group versus 86.8% in the DL group (P = 0.006).

Conclusion

The KVL is a more effective tool to teach endotracheal intubation in comparison to Macintosh laryngoscope in airway novice medical students. Clinical trial registry India registration number: CTRI/2017/11/010491.

Airway devices for awake tracheal intubation in adults: a systematic review and network meta-analysis

BACKGROUND

Awake tracheal intubation is commonly performed with flexible bronchoscopes, but the emerging role of alternative airway devices, such as videolaryngoscopes, direct laryngoscopes, and optical stylets, has been recognised.

METHODS

CENTRAL, CINAHL, EMBASE, MEDLINE, and Web of Science were searched for RCTs that compared flexible bronchoscopes, direct laryngoscopes, optical stylets and channelled or unchannelled videolaryngoscopes in adult patients having awake tracheal intubation were included. The co-primary outcomes were first-pass success rate and time to tracheal intubation. Continuous outcomes were extracted as mean and standard deviation, and dichotomous outcomes were converted to overall numbers of incidence. Frequentist network meta-analysis was conducted, and network plots and network league tables were produced.

RESULTS

Twelve RCTs were included, none of which evaluated direct laryngoscopes. The first-pass success rate was not different between flexible bronchoscopes, optical stylets, and channelled and unchannelled videolaryngoscopes, with the quality of evidence rated as moderate in view of imprecision. Optical stylets, followed by unchannelled videolaryngoscopes and then felxible bronchoscopes resulted in the shortest time to tracheal intubation, with the quality of evidence rated as high. No differences were shown between the airway devices with respect to the incidence of oesophageal intubation, change of airway technique, oxygen desaturation, airway bleeding, or the rate of hoarseness and sore throat.

CONCLUSIONS

Flexible bronchoscopes, optical stylets, and channelled and unchannelled videolaryngoscopes were clinically comparable airway devices in the setting of awake trachela intubation and the time to tracheal intubation was shortest with optical stylets and longest with flexible bronchoscopes.

Use of Video Laryngoscope in Sedated Spontaneously Breathing Patients with Predicted Difficult Tracheal Intubation and Impossibility of Using Fibreoptic Bronchoscopy

Intubation with a flexible fibrobronchoscope in an awake patient is frequently considered the technique of choice in patients with predicted difficult intubation. There are, however, situations in which the use of the fibrobronchoscope is not applicable, particularly due to problems attributable to the patient or to limited use of the instrument. In such situations, the video laryngoscope can be a useful alternative, as long as it is associated with adequate sedation of the patient. In fact, it ensures excellent viewing of the glottis, allowing for successful orotracheal intubation to be performed even in case of difficult airways, while keeping the patient spontaneously breathing throughout the procedure. From the data present in the literature, this technique seems to ensure a success rate and a safety profile similar to those obtained with the fibrobronchoscope, moreover, with greater ease of use by the anaesthesiologist. The main purpose of this work is to provide a valid and safe alternative to intubation with a fibrobronchoscope while awake in those patients with anticipated difficult airway management and in whom, for different reasons, fibrobronchoscope cannot be used.

Three-day tracheal intubation manikin training for novice doctors using Macintosh laryngoscope, McGRATH MAC videolaryngoscope and Pentax AirwayScope

BACKGROUND

We compared the intubation skills obtained by novice doctors following training using 3 instruments, the conventional Macintosh laryngoscope (Mac) and 2 types of indirect video-laryngoscopes (McGrathTM-MAC: McGrath (McG) and AirwayScope (AWS)), to determine the most appropriate instrument for novice doctors to acquire intubation skills, especially focusing on visual confirmation of vocal cords, during a 3-day intensive manikin training program.

METHODS

Fifteen novice doctors who did not have sufficient experience in endotracheal intubation (ETI) and consented to participate in this study were included. We used AirSim and AMT (Airway management Trainer) manikins. First, an experienced anesthesiologist instructed the trainees on using the 3 instruments for a few minutes. Then, after familiarizing themselves with each device for 10 minutes, the participants attempted ETI on the 2 manikins with the 3 devices used in random order. Intubations with each device were practiced and performed for 3 successive days. We assessed the percentage of glottic opening (POGO) score, successful intubation rate and tracheal intubation time for each participant, with each device, and on each day.

RESULTS

In the first manikin, AirSim, POGO scores in the McG and AWS groups were significantly higher than those in the Mac group on all 3 days (P < .0001). The number of intubation failures in the Mac group decreased from 2 cases on day 1, to 1 case on day 2 and zero cases on day 3. There were no failures in the McG and AWS groups on any of the days. With the second manikin, AMT, POGO scores in the Mac group were significantly lower than those in the McG and AWS groups on all 3 days. There were no intubation failures in the AWS group on all 3 days. In the Mac group, the number of intubation failures decreased from 3 on day 1, to 2 on day 2 and zero failures on day 3. In the McG group, there were only 3 failures on day 1.

CONCLUSION

The 2 types of indirect video-laryngoscopes (McGRATH and AirwayScope) were demonstrated to be suitable instruments for novice doctors to achieve higher POGO scores in a 3-day intensive ETI training.

Comparison of the Laryngoscopic View using Macintosh and Miller Blades in Children Less than Four Years Old

This study aimed to compare Miller and Macintosh laryngoscopes in zero to 4-year-old children. A total of 72 children with a score of I and II, according to the American Society of Anesthesiologists (ASA) physical status classification, who were candidates for elective surgery with general anesthesia and tracheal intubation were enrolled in the study. The children were divided into two equal groups (36 persons) according to used laryngoscope: Miller laryngoscope (group 1) and Macintosh laryngoscope (group 2). Observations and all laryngoscopies were performed by a single experienced anesthesiologist. Heart rate, systolic blood pressure, non-invasive arterial blood pressure, and hemoglobin saturation were measured and recorded. The number of endotracheal intubation attempts and complications were also recorded for both groups. In terms of gender, the first group consisted of 88.9% boys and 11.1% girls, and the second group consisted of 66.6% boys and 33.3% girls (p-value=0.05). The mean age was 16.7 months in the first group and 17.7 months in the second group (p-value=0.5). The mean weight of the children was 16988.5 g and 16300 g in the Miller and Macintosh groups, respectively (p-value=0.9). Regarding the Cormack-Lehane classification system, 5 patients were classified as grade 1 (13.9%), 14 patients as grade 2 (38.9%), 15 patients as grade 3 (41.7%), and 2 patients as grade 4 (5.6%) in the Macintosh group. In contrast, in the Miller group, 5 patients were classified as grade 1 (13.9%), 27 patients as grade 2 (75%), and 4 patients as grade 3 (11.1%) (p-value=0.004). These results can provide more data about the tracheal intubation method with the Macintosh and Miller laryngoscopes, the ease of intubation, and the best laryngoscopic view with each blade.

The effects of personal protective equipment on airway management: An in-situ simulation

The novel coronavirus disease (COVID-19) was declared a pandemic by the World Health Organisation on 11th March and has led to over 41,000 deaths in the UK. Public Health England guidance for aerosol generating procedures (AGP) requires the donning of personal protective equipment (PPE). We evaluated airway management skills using an in-situ emergency simulation. The scenarios were video recorded and scored by two independent assessors using a skill specific checklist. A total of 34 airway management procedures were evaluated. The checklist involved 13 steps with a maximum score of 26. The median (IQR [range]) checklist score was 25 (24-25 [20-26]). Four teams failed to intubate the trachea and proceeded to manage the airway using a supraglottic airway device. The mean (SD) intubation time was 47.9 (16.5) seconds and two anaesthetists (7%) required a second attempt. Our results show that airway management can be carried out successfully whilst donned in PPE. However, additional training in using newly introduced devices such as a McGrath® video laryngoscope is of paramount importance.

McGrath MAC video laryngoscope versus direct laryngoscopy for the placement of double-lumen tubes: A randomised control trial

Background and Aims

Role of video laryngoscopes (VLs) in the management of difficult airway with single-lumen tubes (SLTs) is established. VLs provide improved glottis view but are associated with longer time to intubate (TTI). We aimed to compare the TTI for double-lumen tube (DLT) insertion using the McGrath^® MAC VL versus direct Macintosh laryngoscope (DL).

Methods

Eleven senior anaesthesiologists experienced in SLT insertion, but not DLT insertion with VL participated. Seventy-four adults belonging to American Society of Anesthesiologists physical status I-II posted for elective surgery needing lung isolation were randomised to both intubator and laryngoscope (VL/DL). Primary endpoint was TTI; secondary endpoints included glottic view assessed by the Cormack and Lehane (CL) grade, need for external laryngeal manipulation, ease of intubation [scored using Numeric Rating Scale (1 - easiest, 10 - most difficult)] and associated complications. TTI was compared using Student's t-test.

Results

No difference was found in TTI with DL and VL [(56.6 ± 14) s vs (64.4 ± 24) s, P = 0.104] as well as ease of use of laryngoscope [median score of 2 (1-3) in both]. Use of VL resulted in more patients with CL I glottic view - 86.0% versus 58.0% (P = 0.007). Fewer patients required external laryngeal manipulations (19% vs 47%, P = 0.013), and complications were fewer in the VL group (5% vs 24%, P = 0.023).

Conclusion

TTI for DLT insertion was similar with VL and DL. However, VL was associated with better glottis visualisation, reduced need of external laryngeal manipulation and fewer complications.

Impact of a custom-made 3D printed ergonomic grip for direct laryngoscopy on novice intubation performance in a simulated easy and difficult airway scenario-A manikin study

Direct laryngoscopy using a Macintosh laryngoscope is the most widely used approach; however, this skill is not easy for novices and trainees. We evaluated the performance of novices using a laryngoscope with a three-dimensional (3D)-printed ergonomic grip on an airway manikin. Forty second-year medical students were enrolled. Endotracheal intubation was attempted using a conventional Macintosh laryngoscope with or without a 3D-printed ergonomic support grip. Primary outcomes were intubation time and overall success rate. Secondary outcomes were number of unsuccessful attempts, first-attempt success rate, airway Cormack-Lehane (CL) grade, and difficulty score. In the easy airway scenario, intubation time, and the overall success rate were similar between two group. CL grade and ease-of-use scores were significantly better for those using the ergonomic support grip (P < 0.05). In the difficult airway scenario, intubation time (49.7±37.5 vs. 35.5±29.2, P = 0.013), the first-attempt success rate (67.5% vs. 90%, P = 0.029), number of attempts (1.4±0.6 vs. 1.1±0.4, P = 0.006), CL grade (2 [2, 2] vs. 2 [1, 1], P = 0.012), and ease-of-use scores (3.5 [2, 4] vs. 4 [3, 5], P = 0.008) were significantly better for those using the ergonomic support grip. Linear mixed model analysis showed that the ergonomic support grip had a favorable effect on CL grade (P<0.001), ease-of-use scores (P<0.001), intubation time (P = 0.015), and number of intubation attempts (P = 0.029). Our custom 3D-printed ergonomic laryngoscope support grip improved several indicators related to the successful endotracheal intubation in the easy and difficult scenario simulated on an airway manikin. This grip may be useful for intubation training and practice.

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.

Improving pediatric resident laryngoscopy training through the use of a video laryngoscope

IMPORTANCE

Opportunities for pediatric residents to perform direct laryngoscopy and tracheal intubation (DLTI) are few and the success rate is low.

OBJECTIVE

We hypothesize that incorporation of video laryngoscope (McGrath MAC) into pediatric residents DLTI simulation course will improve the simulated DLTI success rate.

METHODS

Residents were given 3 attempts at DLTI: (1) baseline using a conventional laryngoscope (CL); (2) using a video laryngoscope (VL); and (3) again using the CL. Residents were given up to 120 seconds to complete each DLTI attempt. Time to successful DLTI was collected. Residents recorded their best view (larynx, epiglottis, vocal cords) with each DLTI attempt.

RESULTS

Prior to the intervention, 15/17 (88.2%) and 16/17 (94.1%) of the participants reported prior exposure to DLTI as "less than 10 total attempts" in simulated and live patients respectively. Seventeen pediatric residents performed 51 DLTI attempts (34 with a CL and 17 with the VL). Success rates for DLTI are as follows: Baseline with CL 11/17 (64.7%), VL 12/17 (70.6%), and last attempt with CL 13/17 (76.5%) (P = 0.15). Compared to the baseline, the use of VL resulted in a shorter but non-significant decrease in time to successful DLTI (Mean 34.2 sec [SD, 22.0] vs. 56.5 sec [SD, 40.2]; P = 0.08). Repeat attempts at DLTI with the CL, however, were significantly shorter than baseline (Mean 20.3 sec [SD, 12.8] vs. 56.5 sec [SD, 40.2]; P = 0.003). Using the VL, more residents could visualize the vocal cords compared to the baseline (14/17 [82.3%] vs. 9/17 [52.9%]; P = 0.03).

INTERPRETATION

Repeated training is certainly a way to improve successful DLTI. Use of VL as a new teaching method led to greater visualization of the vocal cords, shortening operating time and raising self-confidence.

McGrath videolaryngoscope versus Macintosh laryngoscope for tracheal intubation: A systematic review and meta-analysis with trial sequential analysis

STUDY OBJECTIVE

The McGrath laryngoscope is a novel self-contained videolaryngoscope with a single-use blade. There are several anecdotal reports that the McGrath is superior to the Macintosh laryngoscope for tracheal intubation. However this remains controversial.

DESIGN

Meta-analysis and systematic review.

SETTING

Operating room or intensive care unit.

MEASUREMENTS

A comprehensive literature search was conducted to identify clinical trials that met our inclusion criteria. To qualify, studies had to be prospective randomized trials comparing tracheal intubation between the McGrath and the Macintosh in an adult population. We extracted data on success rate, glottic visualization during intubation, and intubation time from the studies identified. In subgroup analysis, we assessed the influence on each of these parameters which included airway condition (normal or difficult) and operator (novice or experienced). We then conducted a trial sequential analysis (TSA).

MAIN RESULTS

Fourteen articles met our inclusion criteria. The McGrath offered better glottic visualization than the Macintosh (risk ratio, 1.34; 95% confidence interval (CI), 1.25-1.45). However, the McGrath required longer intubation time (mean difference, 10.1s; CI, 2.74-17.5) and demonstrated similar success rate of tracheal intubation (risk ratio, 1.00; CI, 0.95-1.05) compared to the Macintosh. TSA showed that total sample size reached the required information size (RIS) in glottic visualization and success rate. However, only 15.1% of the RIS was achieved in intubation time. In the subgroup analysis for airway condition and operator experience level, there were no subgroup differences in both glottic visualization and intubation time.

CONCLUSIONS

Our meta-analysis suggests that the McGrath is superior to the Macintosh in terms of glottic visualization (GRADE: moderate). However, it significantly extends intubation time (GRADE: very low) and its success rate (GRADE: very low) for tracheal intubation is not excellent. TSA suggests that further studies are necessary to confirm the results of intubation time.

Videolaryngoscopy vs. Macintosh laryngoscopy for double-lumen tube intubation in thoracic surgery: a systematic review and meta-analysis

Double-lumen intubation is more difficult than single-lumen tracheal intubation. Videolaryngoscopes have many advantages in airway management. However, the advantages of videolaryngoscopy for intubation with a double-lumen tube remain controversial compared with traditional Macintosh laryngoscopy. In this study, we searched MEDLINE, Embase, Cochrane Library and the Web of Science for randomised controlled trials comparing videolaryngoscopy with Macintosh laryngoscopy for double-lumen tube intubation. We found that videolaryngoscopy provided a higher success rate at first attempt for double-lumen tube intubation, with an odds ratio (95%CI) of 2.77 (1.92-4.00) (12 studies, 1215 patients, moderate-quality evidence, p < 0.00001), as well as a lower incidence of oral, mucosal or dental injuries during double-lumen tube intubation, odds ratio (95%CI) 0.36 (0.15-0.85) (11 studies, 1145 patients, low-quality evidence, p = 0.02), and for postoperative sore throat, odds ratio (95%CI) 0.54 (0.36-0.81) (7 studies, 561 patients, moderate-quality evidence, p = 0.003), compared with Macintosh laryngoscopy. There were no significant differences in intubation time, with a standardised mean difference (95%CI) of -0.10 (-0.62 to 0.42) (14 studies, 1310 patients, very low-quality evidence, p = 0.71); and the incidence of postoperative voice change, odds ratio (95%CI) 0.53 (0.21-1.31) (7 studies, 535 patients, low-quality evidence, p = 0.17). Videolaryngoscopy led to a higher incidence of malpositioned double-lumen tube, with an odds ratio (95%CI) of 2.23 (1.10-4.52) (six studies, 487 patients, moderate-quality evidence, p = 0.03).

Comparison of VividTrac®, Airtraq®, King Vision®, Macintosh Laryngoscope and a Custom-Made Videolaryngoscope for difficult and normal airways in mannequins by novices

BACKGROUND

Direct laryngoscopy remains the gold standard for endotracheal intubation and is preferred by experienced operators. However, an increasing number of reports currently support videolaryngoscopy, particularly for novice users. The widespread use of videolaryngoscopy may be limited due to financial limitations, especially in low-income countries. Therefore, affordable single-use scopes are now becoming increasingly popular. We sought to compare these new scopes with direct laryngoscopes and the previously tested videolaryngoscopes in mannequins by novices.

METHODS

Fifty medical students were recruited to serve as novice users. Following brief, standardized training, students were asked to execute endotracheal intubation with each of the devices, including the Airtraq®, a custom-made videolaryngoscope, the King Vision®, the Macintosh laryngoscope and the VividTrac®, on an airway trainer (Laerdal Airway Management Trainer®) in normal and difficult airway scenarios. We evaluated the time to and the proportion of successful intubation, the best view of the glottis, esophageal intubation, dental trauma and user satisfaction.

RESULTS

We observed no differences in esophageal intubation. However, intubation-related times, the view of the glottis and operator satisfaction were significantly better throughout the study with the commercial videolaryngoscopes. In comparison, the custom-made videolaryngoscope performance proved to be similar to that of the Macintosh laryngoscope. The VividTrac® performance was similar (P > 0.05) or significantly better than that of the King Vision® in both scenarios.

CONCLUSIONS

Based upon our results, the Airtraq®, King Vision® and VividTrac® were superior to the Macintosh laryngscope in both normal and difficult airway scencarios for novice users. In particular, our study is the first to report that the VividTrac® shows promise for further clinical evaluation.

Learning Neonatal Intubation Using the Videolaryngoscope: A Randomized Trial on Mannequins

INTRODUCTION

The use of the videolaryngoscope (VL) facilitates intubation in adults and children, but experience in neonates is scarce. The objective of this study was to compare the VL with the classic laryngoscope (CL) in acquiring the skill of neonatal endotracheal intubation (ETI) and evaluate transferability of skill from VL to CL. We hypothesize that, on a neonatal mannequin, the VL will be superior to the CL with regard to success rate and that the skill will be transferred from VL to CL.

METHODS

A randomized controlled trial was held at Sainte-Justine Hospital's simulation center. Third- and fourth-year medical students were randomized into group A, which used VL for the first phase and CL for the second phase, and group B, which used CL for both phases. Each subject performed 9 ETI on 3 simulated neonatal airways in each phase.

RESULTS

Thirty-four students performed 612 intubations. Success in group A was higher than in group B in the first phase of the study (96.5% vs. 84.6%, P < 0.001). During phase 2, group A's success did not change significantly (91.7% vs. 96.5%, P = 0.07). Time to successful intubation was longer using the VL (27.6 vs. 15.6 seconds, P < 0.001), but there was no difference in phase 2 (12.5 vs. 10.2 seconds, P = 0.24). There were no esophageal intubations using the VL.

CONCLUSIONS

Success rate of ETI on mannequins was improved, and esophageal intubations decreased while learning ETI using the VL compared with the CL. Once ETI is learned on mannequins using the VL, this skill is transferrable to the CL.

A comparison of the Airtraq®, McGrath®, and Macintosh laryngoscopes for difficult paediatric intubation: A manikin study

BACKGROUND

The efficacy of devices for difficult intubation in paediatric patients, especially with a Cormack-Lehane grade 4 view, has yet to be established. We compared intubating parameters among three devices (the Airtraq®, McGrath®, and Macintosh laryngoscopes).

METHODS

This study is a randomised cross-over trial. Participants were 20 anaesthetists. Each device was tested three times using a paediatric manikin with a Cormack-Lehane grade 4 view. The order to use each device was randomised by a computer-generated random sequence. The primary endpoint was the rate of successful intubation. Secondary endpoints included the time taken to intubate, percentage of glottic opening score, and severity of potential dental trauma.

RESULTS

The successful intubation rates of the Airtraq®, McGrath®, and Macintosh laryngoscopes were 100%, 72%, and 45%, respectively. The risk ratio of the success rates of Airtraq® compared with McGrath® and Macintosh laryngoscopes were 1.40 (95% CI; 1.19-1.64, P < 0.001) and 2.22 (95% CI; 1.68-2.94, P < 0.001), respectively. The modified Cormack-Lehane grade and percentage of the glottic opening score were better for the Airtraq® than for the other devices. The dental trauma score was lower for the Airtraq® than for the other devices. There were no significant differences in the intubation time among the groups.

CONCLUSIONS

The Airtraq® had higher success rate, had better visibility, and was associated with less dental trauma than the other devices in a difficult paediatric intubation model with a Cormack-Lehane grade 4 view.

Transfer of skills and comparison of performance between king vision® video laryngoscope and macintosh blade following an AHA airway management course

Background

To potentially optimize intubation skill teaching in an American Heart Association® Airway Management Course® for novices, we investigated the transfer of skills from video laryngoscopy to direct laryngoscopy and vice versa using King Vision® and Macintosh blade laryngoscopes respectively.

Methods

Ninety volunteers (medical students, residents and staff physicians) without prior intubation experience were randomized into three groups to receive intubation training with either King Vision® or Macintosh blade or both. Afterwards they attempted intubation on two human cadavers with both tools. The primary outcome was skill transfer from video laryngoscopy to direct laryngoscopy assessed by first attempt success rates within 60 s. Secondary outcomes were skill transfer in the opposite direction, the efficacy of teaching both tools, and the success rates and esophageal intubation rates of Macintosh blade versus King Vision®.

Results

Performance with the Macintosh blade was identical following training with either Macintosh blade or King Vision® (unadjusted odds ratio [OR] 1.09, 95% confidence interval [95% CI] 0.5–2.6). Performance with the King Vision® was significantly better in the group that was trained on it (OR 2.7, 95% CI 1.2–5.9). Success rate within 60 s with Macintosh blade was 48% compared to 52% with King Vision® (OR 0.85, 95% CI 0.4–2.0). Rate of esophageal intubations with Macintosh blade was significantly higher (17% versus 4%, OR 5.0, 95% CI 1.1–23).

Conclusions

We found better skill transfer from King Vision® to Macintosh blade than vice versa and fewer esophageal intubations with video laryngoscopy. For global skill improvement in an airway management course for novices, teaching only video laryngoscopy may be sufficient. However, success rates were low for both devices.

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-016-0296-9) contains supplementary material, which is available to authorized users.

McGrath Series 5 videolaryngoscope vs Airtraq DL videolaryngoscope for double-lumen tube intubation: A randomized trial

BACKGROUND

Many studies have shown Airtraq videolaryngoscope provided faster tracheal intubation and a higher success rate than other videolaryngoscopes. Recently, different types of videolaryngoscopes have been reported for use in double-lumen tube (DLT) intubation. However, the advantages and disadvantages between them remain undetermined for DLT intubation. In this study, we compared the Airtraq DL videolaryngoscope with the McGrath Series 5 videolaryngoscope for DLT intubation by experienced anesthesiologists.

METHODS

Ninety patients with expected normal airways were randomly allocated to either the Airtraq or McGrath group. The primary outcome was DLT intubation time. The secondary outcomes were glottic view, success rate, subjective ease of intubation (100-mm visual analog scale, 0 = easy; 100 = difficult), incidence of DLT malposition, and postoperative intubation-related complication.

RESULTS

The airway characteristics were comparable between the 2 groups. Cormack and Lehane grades significantly improved with the use of the McGrath and Airtraq videolaryngoscopes, compared with the Macintosh laryngoscope. The intubation success rate on the first attempt was 93% in the Airtraq group and 95% in the McGrath group (P > 0.05). The intubation time in the McGrath group is longer than that in the Airtraq group (39.9 [9.1]s vs 28.6 [13.6]s, P < 0.05). But intubation difficulty score, the incidence of DLT malposition and intubation-related complication were comparable between groups (P > 0.05).

CONCLUSIONS

When using videolaryngoscopes for DLT intubation, the Airtraq DL is superior to the McGrath Series 5 in intubation time, but it does not decrease intubation difficulty.

Comparison of McGrath(®) Series 5 video laryngoscope with Macintosh laryngoscope: A prospective, randomised trial in patients with normal airways

Objective:

The McGrath Video laryngoscope is a newly developed video laryngoscope that significantly improves laryngeal view and facilitates endotracheal intubation in difficult airways. However in patients with normal airway that is not mentioned before. The aim of this study was to compare the McGrath video laryngoscope with the Macintosh laryngoscope in patients with normal airways.

Methods:

A total of 100 patients requiring orotracheal intubation, were randomized to either having intubation with the McGrath video laryngoscope or the Macintosh laryngoscope. The primary outcome was the laryngoscopy view using percentage of glottic opening (POGO) score. Secondary outcomes included Cormack and Lehane grading system, time to intubation, number of failed intubations, number of attempts before successful intubation and hemodynamic parameters during intubation.

Results:

POGO scores were significantly higher in the McGrath group compared with the Macintosh group (p<0.001) despite time to successful intubation was similar in both groups. The McGrath video laryngoscope provided more Grade-I laryngoscopic views than the Macintosh laryngoscope (p<0.001). Number of more than one attempts in order to achieve success was significantly higher in the Macintosh group (p=0.001). The number of minor complications were significantly higher in the Macintosh group (p=0.004). There were no significant changes in hemodynamic responses between the two groups (p>0.05).

Conclusion:

McGrath video laryngoscope allows patients with normal airways to achieve higher POGO scores and significantly more Grade-I laryngoscopic views when compared with the Macintosh laryngoscope.

Comparing McGRATH® MAC, C-MAC®, and Macintosh Laryngoscopes Operated by Medical Students: A Randomized, Crossover, Manikin Study

We hypothesized that the McGRATH MAC would decrease the time of intubation compared to C-MAC for novices. Thirty-nine medical students who had used the Macintosh blade to intubate a manikin fewer than 3 times were recruited. The participants performed sequential intubations on the manikin in two simulated settings that included a normal airway and a difficult airway (tongue edema). The intubation time, success rate of intubation, Cormack-Lehane grade at laryngoscopy, and difficulty using the device were recorded. Each participant was asked to identify the device that was most useful. The intubation time decreased significantly and by a similar amount to the McGRATH MAC and C-MAC compared to the Macintosh blade (P < 0.001 and P = 0.017, resp.). In the difficult airway, the intubation times were similar among the three devices. The McGRATH MAC and C-MAC significantly increased the success rate of intubation, improved the Cormack-Lehane grade, and decreased the difficulty score compared to the Macintosh blade in both airway settings. The majority of participants selected the McGRATH MAC as the most useful device. The McGRATH MAC and C-MAC may offer similar benefits for intubation compared to the Macintosh blade in normal and difficult airway situations.

Comparison of the force applied on oral structures during intubation attempts by novice physicians between the Macintosh direct laryngoscope, Airway Scope and C-MAC PM: a high-fidelity simulator-based study

OBJECTIVE

We examined whether the use of Airway Scope (AWS) and C-MAC PM (C-MAC) decreased the force applied on oral structures during intubation attempts as compared with the force applied with the use of Macintosh direct laryngoscope (DL).

DESIGN

Prospective cross-over study.

PARTICIPANTS

A total of 35 novice physicians participated.

INTERVENTIONS

We used 6 simulation scenarios based on the difficulty of intubation and intubation devices.

OUTCOME MEASURES

Our primary outcome measures were the maximum force applied on the maxillary incisors and tongue during intubation attempts, measured by a high-fidelity simulator.

RESULTS

The maximum force applied on maxillary incisors was higher with the use of the C-MAC than with the DL and AWS in the normal airway scenario (DL, 26 Newton (N); AWS, 18 N; C-MAC, 52 N; p<0.01) and the difficult airway scenario (DL, 42 N; AWS, 24 N; C-MAC, 68 N; p<0.01). In contrast, the maximum force applied on the tongue was higher with the use of the DL than with the AWS and C-MAC in both airway scenarios (DL, 16 N; AWS, 1 N; C-MAC, 7 N; p<0.01 in the normal airway scenario; DL, 12 N; AWS, 4 N; C-MAC, 7 N; p<0.01 in the difficult airway scenario).

CONCLUSIONS

The use of C-MAC, compared with the DL and AWS, was associated with the higher maximum force applied on maxillary incisors during intubation attempts. In contrast, the use of video laryngoscopes was associated with the lower force applied on the tongue in both airway scenarios, compared with the DL. Our study was a simulation-based study, and further research on living patients would be warranted.

[A randomised crossover trial comparing the Airtraq(®) NT, McGrath(®) MAC and Macintosh laryngoscopes for nasotracheal intubation of simulated easy and difficult airways in a manikin]

OBJECTIVE

Several devices can aid nasotracheal intubation when managing difficult airways. The McGrath MAC and Airtraq NT were compared with a Macintosh laryngoscope when studying the performance of anaesthetists with different levels of experience, in a manikin model of easy or difficult airway scenarios.

METHODS

Sixty-three anaesthetists were recruited into a randomised trial in which each performed nasotracheal intubation with all laryngoscopes, in both scenarios. The main endpoint was intubation time. Additional endpoints included laryngoscopic view, intubation success, number of optimisation manoeuvres, audible dental clicks and the force applied to the upper airway.

RESULTS

Intubation time was significantly shorter using the McGrath MAC in both scenarios and using the Airtraq in the difficult scenario, when compared with the Macintosh laryngoscope. Both devices gave more Cormack and Lehane grade 1 or 2 views than the Macintosh in the difficult scenario (p<0.001). The McGrath MAC had the best first-attempt success rate (98.4% vs. 96.8% and 95.8%, p<0.001 for the Airtraq NT and Macintosh laryngoscopes respectively). The number of optimisation manoeuvres, audible dental clicks and subjective assessment of the degree of force applied were significantly lower for indirect laryngoscopes versus the Macintosh laryngoscope (p<0.001).

CONCLUSION

In a manikin, the Airtraq and the McGrath laryngoscopes appeared superior to the Macintosh laryngoscope when dealing with simulated airway scenarios. Both devices were associated with better views, intubation times and rates of success, especially in a simulated "difficult airway". Overall satisfaction was highest with the McGrath laryngoscope. Similar clinical studies are needed.

Use of the GlideScope®-Ranger for pre-hospital intubations by anaesthesia trained emergency physicians - an observational study

Background

Pre-hospital endotracheal intubation is more difficult than in the operating room (OR). Therefore, enhanced airway management devices such as video laryngoscopes may be helpful to improve the success rate of pre-hospital intubation. We describe the use of the Glidescope®-Ranger (GS-R) as an alternative airway tool used at the discretion of the emergency physician (EP) in charge.

Methods

During a 3.5 year period, the GS-R was available to be used either as the primary or backup tool for pre-hospital intubation by anaesthesia trained EP with limited expertise using angulated videolaryngoscopes.

Results

During this period 672 patients needed pre-hospital intubation of which the GS-R was used in 56 cases. The overall GS-R success rate was 66 % (range of 34–100 % among EP). The reasons for difficulties or failure included inexperience of the EP with the GS-R, impaired view due to secretion, vomitus, blood or the inability to see the screen in very bright environment due to sunlight.

Conclusion

Special expertise and substantial training is needed to successfully accomplish tracheal intubation with the GS-R in the pre-hospital setting. Providers inexperienced with DL as well as video-assisted intubation should not expect to be able to perform tracheal intubation easily just because a videolaryngoscope is available. Additionally, indirect laryngoscopy might be difficult or even impossible to achieve in the pre-hospital setting due to impeding circumstances such as blood, secretions or bright sun-light. Therefore, videolaryngoscopes, here the GS-R, should not be considered as the “Holy Grail” of endotracheal intubation, neither for the experts nor for inexperienced providers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12873-016-0069-2) contains supplementary material, which is available to authorized users.

[Educational suitability of endotracheal intubation using a video-laryngoscope]

PURPOSE

The purpose of this study is to determine the educational suitability of the video-laryngoscope in teaching endotracheal intubation to students.

METHODS

Medical students participated in a course on the use of a Macintosh direct laryngoscope and McGrath MAC videolaryngoscope for intubation. The course comprised a 1-hour lecture and 30 minutes of practice on a manikin. After the course, in each of the three simulated patient scenarios-normal airway, cervical spine fixation, and tongue edema-time to intubate, success rate, and chance of complications were measured. A questionnaire was administered before and after the course to determine thesuitability of intubation by video-laryngoscope for a medical education course. Also, changes in the perception and stance on the video-laryngoscope were evaluated.

RESULTS

Time to intubate decreased as attempts were repeated. The first-attempt success rate in the cervical spine fixation scenario was higher using the video-laryngoscope (p=0.028). Rates if tooth injury were lower in the cervical spine fixation (p=0.005) andtongue edema scenarios (p=0.021) using the video-laryngoscope. Based on the questionnaires, students responded positively with regard to their knowledge of the video-laryngoscope, its practical value, and its suitability for medical education (p<0.001). Also,the preference for the video-laryngoscope was greater (p=0.044). Students felt that repeated attempts and feedback on intubation were helpful.

CONCLUSION

The students' evaluations and surveys showed positive results to intubation by video-laryngoscope. Thus, based on its suitability for medical education it is reasonable to consider learning intubation using the video-laryngoscope.

A comparison of the McGrath-MAC and Macintosh laryngoscopes for child tracheal intubation during resuscitation by paramedics. A randomized, crossover, manikin study

INTRODUCTION

Prehospital tracheal intubation by paramedics during cardiopulmonary resuscitation (CPR) in children is challenging. The potential role of new intubation devices during CPR is unclear. Our objective was to assess the impact of CPR (with and without chest compressions [CCs]) on the success and time to intubation (TTI) with the Macintosh laryngoscope vs the McGrath video laryngoscope on a pediatric manikin.

METHODS

This was an open, prospective, randomized, crossover, manikin trial involving 95 paramedics who performed intubations in a PediaSIM pediatric high-fidelity manikin with Macintosh and McGrath laryngoscopes, with and without concomitant mechanical CCs. Primary outcome was the TTI, and secondary outcome was success of the attempt. Participants rated their best glottic view, the severity of the potential dental trauma, and subjective opinion about the difficulty of the procedure.

RESULTS

The median TTI with the Macintosh in the scenario with uninterrupted CC was 33 (interquartile range [IQR], 24-36) seconds, which is significantly longer than TTI in the scenario with interrupted CC (23 [IQR, 20-29] seconds, P < .001). Time to intubation using the McGrath was similar in both scenarios: 20 (IQR, 17-23) seconds vs 19.5 (IQR, 17-22) seconds (P = .083). A statistically significant difference between McGrath and Macintosh was noticed in TTI both in scenario with (P < .001) and without CC (P = .017).

CONCLUSIONS

McGrath video laryngoscope helps paramedics to intubate a pediatric manikin in a CPR scenario in less time and with fewer attempts than with the classical Macintosh, both in case of ongoing or stopped CC. McGrath use in actual patients could improve CPR quality by paramedics.

A prospective, randomised, clinical study to compare the use of McGrath(®), Truview(®) and Macintosh laryngoscopes for endotracheal intubation by novice and experienced Anaesthesiologists

Background and Aims:

Video laryngoscopy has been recommended as an alternative during difficult conventional direct laryngoscopy using the Macintosh blade (MAC). However, successful visualisation of the larynx and tracheal intubation using some of the indirect laryngoscopes or video laryngoscopes (VL) requires hand-eye coordination. We conducted this study to determine whether non-channel VLs are easy to use for novices and whether there is any association between expertise with MAC and ease of tracheal intubation with VLs.

Methods:

Anaesthesiologists participating in the study were divided into three groups: Group novice to intubation (NTI), Group novice to videoscope (NVL)- experienced with MAC, novice to VLs and Group expert (EXP) experienced in all. Group NTI, NVL received prior mannequin training. VLs- Truview^® and McGrath series 5 (MGR) were compared with MAC. One hundred and twenty six adult patients with normal airway were randomised to both, the intubating anaesthesiologist and laryngoscope. The time taken to intubate (TTI) and participants’ rating of the ease of use was recorded on a scale of 1–10 (10-most difficult).

Results:

In Group NTI, there was no difference in mean TTI with the three scopes (P = 0.938). In Group NVL, TTI was longer with the VLs than MAC (P < 0.001). In Group EXP, TTI with VL took 20 s more (P < 0.001). There was significant difference in participants’ rating of ease of use of laryngoscope in Group NVL (P = 0.001) but not in the NTI (P = 0.205), EXP (P = 0.529) groups. A high failure was seen with MGR in Group NTI and NVL.

Conclusion:

In Group NTI, TTI and the ease of use were similar for all scopes. Expertise with standard direct laryngoscopy does not translate to expertise with VLs. Separate training and experience with VLs is required.

McGrath Video Laryngoscopy Facilitates Routine Nasotracheal Intubation in Patients Undergoing Oral and Maxillofacial Surgery: A Comparison With Macintosh Laryngoscopy

PURPOSE

The McGrath video laryngoscope (VL) offers excellent laryngoscopic views and increases the success rate of orotracheal intubation in patients with normal and difficult airways. The purpose of this randomized controlled trial was to compare the McGrath VL with the Macintosh laryngoscope to investigate the efficacy of the McGrath VL for routine nasotracheal intubation in patients with an expected normal airway.

MATERIALS AND METHODS

To address the research purpose, the efficacy of the McGrath VL for routine nasotracheal intubation was compared with that of the Macintosh laryngoscope. The predictor variable was the laryngoscopic technique (McGrath VL vs Macintosh laryngoscope). The outcome variables were the time to successful intubation, laryngoscopic views before and after optimal external laryngeal manipulation (OELM), use of Magill forceps, ease of intubation, and severity of oropharyngeal bleeding.

RESULTS

Data from 35 patients undergoing oral and maxillofacial surgery were assessed. The time to intubation was 10.5 seconds shorter in the McGrath group than in the Macintosh group (34.4 ± 13.7 vs 44.9 ± 15.6 seconds; P = .004). The incidence of grade 1 glottic view before OELM was higher in the McGrath group than in the Macintosh group (83 vs 57%; P = .019). The frequency of Magill forceps use was lower in the McGrath group than in the Macintosh group (6 vs 34%; P = .003).

CONCLUSION

McGrath VL facilitates routine nasotracheal intubation in expected normal airways by providing a shorter intubation time and better laryngoscopic views compared with the Macintosh laryngoscope.

The comparison of the technical parameters in endotracheal intubation devices: the Cmac, the Vividtrac, the McGrath Mac and the Kingvision

Currently, there are plenty of videolaryngoscopes that appear on the market. They have different specifications. Some of these features favor the fact that they are more suited for educational purposes of future operators and others can be characterized with an excellent clinical use. In this study we compared four types of videolaryngoscopes. The aim of the study was to compare the technical specifications of the above-mentioned devices for usefulness in clinical practice and correlate these parameters with the subjective evaluation of these videolaryngoscopes usage performed in practice by an experienced medical staff. All devices considered in this study participated in another multicenter clinical study on the basis of which we completed the subjective evaluation of the operators. In order to examine the technical parameters of the equipment we established the cooperation with the Department of Microelectronics at Technical University of Lodz. Mechanical and optical parameters and the endoscopic tube current were taken into consideration. The C-MAC has a camera with the widest viewing angle (the OX axis-63.1, the axis OY-47.8), which in combination with the largest diagonal size of the display enables the operator to see the details relevant to clinical practice. It has also the strongest lamp intensity of the devices mentioned in this comparison (7800 Lx). In comparison of the clinical use in almost all compared parameters the Cmac D-blade is a winner, although for clinical education purpose we consider the Vividtrac a better device.

A randomised crossover trial comparing the Airtraq(®) NT, McGrath(®) MAC and Macintosh laryngoscopes for nasotracheal intubation of simulated easy and difficult airways in a manikin

OBJECTIVE

Several devices can aid nasotracheal intubation when managing difficult airways. The McGrath MAC and Airtraq NT were compared with a Macintosh laryngoscope when studying the performance of anaesthetists with different levels of experience, in a manikin model of easy or difficult airway scenarios.

METHODS

Sixty-three anaesthetists were recruited into a randomised trial in which each performed nasotracheal intubation with all laryngoscopes, in both scenarios. The main endpoint was intubation time. Additional endpoints included laryngoscopic view, intubation success, number of optimisation manoeuvres, audible dental clicks and the force applied to the upper airway.

RESULTS

Intubation time was significantly shorter using the McGrath MAC in both scenarios and using the Airtraq in the difficult scenario, when compared with the Macintosh laryngoscope. Both devices gave more Cormack and Lehane grade 1 or 2 views than the Macintosh in the difficult scenario (p<0.001). The McGrath MAC had the best first-attempt success rate (98.4% vs. 96.8% and 95.8%, p<0.001 for the Airtraq NT and Macintosh laryngoscopes respectively). The number of optimisation manoeuvres, audible dental clicks and subjective assessment of the degree of force applied were significantly lower for indirect laryngoscopes versus the Macintosh laryngoscope (p<0.001).

CONCLUSION

In a manikin, the Airtraq and the McGrath laryngoscopes appeared superior to the Macintosh laryngoscope when dealing with simulated airway scenarios. Both devices were associated with better views, intubation times and rates of success, especially in a simulated "difficult airway". Overall satisfaction was highest with the McGrath laryngoscope. Similar clinical studies are needed.

Does Video Laryngoscopy Offer Advantages over Direct Laryngoscopy during Cardiopulmonary Resuscitation?

OBJECTIVE

Interruption of chest compressions should be minimized because of its negative effects on survival. This randomized, controlled, cross-over study aimed to analyze the effectiveness of Macintosh, Miller, McCoy and McGrath laryngoscopes during with or without chest compressions in the scope of a simulated cardiopulmonary resuscitation scenario.

METHODS

The time required for successful tracheal intubation, number of attempts, dental trauma severity and the need for optimization manoeuvres were recorded during cardiopulmonary resuscitation with and without chest compressions. The experience with computer games during the last 10 years were asked to the participants and recorded.

RESULTS

McCoy laryngoscope yielded the shortest time for successful tracheal intubation both in the presence of and without chest compressions. During the use of McCoy laryngoscopes, fewer tracheal intubation attempts, lower incidence of dental trauma and lower visual analogue scale scores on the ease of intubation were recorded. Participants who are experienced computer game players using Macintosh, McCoy and McGrath achieved successful tracheal intubation in a significantly shorter time during resuscitation without chest compressions. Dental trauma incidence and number of tracheal intubation attempts did not show any significant difference between the four laryngoscopes being related to the rate of playing computer games.

CONCLUSION

McGrath video laryngoscopes do not appear to have advantages over direct laryngoscopes for securing a smooth and successful tracheal intubation during rhythmic chest compressions. We believe that as McCoy laryngoscope provided tracheal intubation in a shorter time and with fewer attempts, this laryngoscope may increase the success rate of resuscitation.