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Alsabri M, Abdelwahab OA, Elsnhory AB, Diab RA, Sabesan V, Ayyan M, McClean C, Alhadheri A. Video laryngoscopy versus direct laryngoscopy in achieving successful emergency endotracheal intubations: a systematic review and meta-analysis of randomized controlled trials. Syst Rev 2024; 13:85. [PMID: 38475918 DOI: 10.1186/s13643-024-02500-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 02/20/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Intubating a patient in an emergent setting presents significant challenges compared to planned intubation in an operating room. This study aims to compare video laryngoscopy versus direct laryngoscopy in achieving successful endotracheal intubation on the first attempt in emergency intubations, irrespective of the clinical setting. METHODS We systematically searched PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials from inception until 27 February 2023. We included only randomized controlled trials that included patients who had undergone emergent endotracheal intubation for any indication, regardless of the clinical setting. We used the Cochrane risk-of-bias assessment tool 2 (ROB2) to assess the included studies. We used the mean difference (MD) and risk ratio (RR), with the corresponding 95% confidence interval (CI), to pool the continuous and dichotomous variables, respectively. RESULTS Fourteen studies were included with a total of 2470 patients. The overall analysis favored video laryngoscopy over direct laryngoscopy in first-attempt success rate (RR = 1.09, 95% CI [1.02, 1.18], P = 0.02), first-attempt intubation time (MD = - 6.92, 95% CI [- 12.86, - 0.99], P = 0.02), intubation difficulty score (MD = - 0.62, 95% CI [- 0.86, - 0.37], P < 0.001), peri-intubation percentage of glottis opening (MD = 24.91, 95% CI [11.18, 38.64], P < 0.001), upper airway injuries (RR = 0.15, 95% CI [0.04, 0.56], P = 0.005), and esophageal intubation (RR = 0.37, 95% CI [0.15, 0.94], P = 0.04). However, no difference between the two groups was found regarding the overall intubation success rate (P > 0.05). CONCLUSION In emergency intubations, video laryngoscopy is preferred to direct laryngoscopy in achieving successful intubation on the first attempt and was associated with a lower incidence of complications.
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Affiliation(s)
- Mohammed Alsabri
- Department of Emergency Medicine, Al-Thawra Modern General Teaching Hospital, Sana'a City, Yemen.
| | | | | | | | | | | | | | - Ayman Alhadheri
- Michigan State University College of Osteopathic Medicine, East Lansing, USA
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Chien YT, Ong JR, Tam KW, Loh EW. Video laryngoscopy and direct laryngoscopy for cardiac arrest: A meta-analysis of clinical studies and trials. Am J Emerg Med 2023; 73:116-124. [PMID: 37647846 DOI: 10.1016/j.ajem.2023.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 08/11/2023] [Accepted: 08/11/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Intubation is an essential procedure in cardiopulmonary resuscitation (CPR). We conducted a systematic review and meta-analysis of trials and studies comparing the performance of video laryngoscope (VL) and direct laryngoscope (DL) in endotracheal intubation (ETI) during CPR in cardiac arrest (OHCA) patients. METHODS We searched the PUBMED, EMBASE, and Cochrane library databases. We analyzed the first-pass success rate, total intubation time, Cormack-Lehane grade (CL grade), esophageal intubation rate, and dental injury rate among the in-hospital cardiac arrest (IHCA) patients or out-of-hospital cardiac arrest (OHCA) patients. We demonstrated the pooled results of continuous outcomes by mean difference (MD) and dichotomous outcomes by odds ratio (OR), with a 95% confidence interval (CI) using a random-effects model. RESULTS We obtained six observational studies and one randomized control trial. The pooled results showed a significant increase in first-pass success rate (OR: 1.86, 95% CI: 1.41, 2.47), Cormack-Lehane (CL) grade (OR: 2.01, 95% CI: 1.59,2.53), and a decrease of esophageal intubation rate (OR: 0.25, 95% CI: 0.08, 0.85) in the VL group compared with DL group. Also, a non-significant decrease in dental injury rate [OR: 0.23, 95% CI: 0.05, 1.08) was observed in the VL group compared with the DL group. There was no statistical difference between the VL and DL groups, although the VL group seemed to have a shorter total intubation time (MD: -15.43, 95% CI: -34.67, 3.81). Types of laryngoscopes were not associated with the rate of ROSC [OR 1.01 (0.95,1.07); P = 0.83]. No differences in survival outcomes were observed between the two approaches. CONCLUSIONS Compared to DL, VL was found to be associated with first-pass success and CL grade. We recommend prioritizing VL over DL when performing ETIs for patients with cardiac arrest.
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Affiliation(s)
- Yu-Ta Chien
- Department of Emergency Medicine, Mennonite Christian Hospital, Emergency Department, Hualien City, Taiwan
| | - Jiann-Ruey Ong
- Department of Emergency Medicine, Taipei Medical University Shuang-Ho Hospital, New Taipei City, Taiwan
| | - Ka-Wai Tam
- Division of General Surgery, Department of Surgery, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan; Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Center for Evidence-Based Health Care, Department of Medical Research, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
| | - El-Wui Loh
- Center for Evidence-Based Health Care, Department of Medical Research, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan; Department of Medical Imaging, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan.
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Lee JY, Hur HJ, Park HY, Jung WS, Kim J, Kwak HJ. Comparison between video-lighted stylet (Intular Scope™) and direct laryngoscope for endotracheal intubation in patients with normal airway. J Int Med Res 2021; 48:300060520969532. [PMID: 33167759 PMCID: PMC7658531 DOI: 10.1177/0300060520969532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective The Intular Scope™ (Medical Park, South Korea) (IS) is a video-lighted stylet that can be used for endotracheal intubation with excellent visualization by adding a camera to its end. We compared the efficacy of a direct laryngoscope (DL) with that of the IS based on hemodynamic changes, ease of intubation, and postoperative airway morbidities. Methods Seventy patients with expected normal airways were randomized for intubation using an IS (n = 35) or DL (n = 35). The primary outcome was the mean arterial pressure during intubation. The secondary outcomes were the time to intubation (TTI), percentage of glottic opening (POGO) score, and number of intubation attempts. The incidence and severity of bleeding, hoarseness, and sore throat after intubation were also recorded. Results Hemodynamic changes during intubation were not significantly different between the groups. The TTI was longer in the IS than DL group. The POGO score was higher in the IS than DL group. Hoarseness and sore throat were significantly less severe in the IS than DL group. Conclusions Using the IS did not significantly improve hemodynamics and resulted in a longer TTI. However, the IS was associated with less severe postoperative airway morbidities compared with the DL.
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Affiliation(s)
- Ji Yeon Lee
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Incheon, South Korea
| | - Ho Jin Hur
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hee Yeon Park
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Incheon, South Korea
| | - Wol Seon Jung
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Incheon, South Korea
| | - Jiro Kim
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Incheon, South Korea
| | - Hyun Jeong Kwak
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Incheon, South Korea
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Li WX, Dong Y, Zhang A, Tian J, Lu C, Jeannon JP, Liu L. Surgical treatment of fourth branchial apparatus anomalies: a case series study. J Otolaryngol Head Neck Surg 2020; 49:79. [PMID: 33198806 PMCID: PMC7670670 DOI: 10.1186/s40463-020-00477-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 11/02/2020] [Indexed: 11/17/2022] Open
Abstract
Background Fourth branchial apparatus anomalies, are rare clinical entities, and present as complex cysts, sinuses and fistulae in the neck that can be difficult to manage. Methods This is a retrospective review of a series of consecutive patients with fourth branchial apparatus anomalies treated at Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, from Apr 2014 to Nov 2019. Results Ten patients with fourth branchial apparatus anomalies were identified, including 8 patients with fourth branchial fistula, and 2 patients with fourth branchial pouch sinus. There were 6 female patients and 4 male patients. Their age was from 6 years old to 39 years old (average age 20.4 years old, median age was 21 years old). All 8 fistulae were on the left side, while 2 pouch sinuses were both on the right side. Pre-operative examination with fiberoptic laryngoscope, barium swallow X-ray, CT or MRI identified internal orifice at pyriform fossa apex in 8 (80%) patients. All patients underwent challenging surgical resection by the senior author. Intra-operative direct laryngoscope confirmed or identified internal orifice in 9 (90%) patients. The tracts were all followed to the vicinity of inferior cornu of the thyroid cartilage and the cricothyroid space. Complete resection of cervical lesions and their attachment to hypopharynx were achieved in 9 cases. No complication occurred. One recurrence was detected, in the only patient whose internal orifice could not be located pre- or intra-operatively, and the hypopharyngeal attachment could not be removed. Conclusions Direct laryngoscopy under general anesthesia is a reliable method of diagnosis for the fourth branchial apparatus anomalies. Complete surgical removal of fourth branchial apparatus anomalies, including their hypopharyngeal attachment, is the treatment of choice, and the key to prevent recurrence.
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Affiliation(s)
- Wan-Xin Li
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, 95th Yong'an Road, Xicheng District, Beijing, 100050, China
| | - Yanbo Dong
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, 95th Yong'an Road, Xicheng District, Beijing, 100050, China
| | - Aobo Zhang
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, 95th Yong'an Road, Xicheng District, Beijing, 100050, China
| | - Jun Tian
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, 95th Yong'an Road, Xicheng District, Beijing, 100050, China
| | - Cheng Lu
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, 95th Yong'an Road, Xicheng District, Beijing, 100050, China
| | - Jean Pierre Jeannon
- Surgical Oncology, Guy's & St Thomas NHS Hospital, Kings College London, London, UK
| | - Liangfa Liu
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, 95th Yong'an Road, Xicheng District, Beijing, 100050, China.
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Lin YC, Cho AH, Lin JR, Chung YT. The Clarus Video System (Trachway) and direct laryngoscope for endotracheal intubation with cricoid pressure in simulated rapid sequence induction intubation: a prospective randomized controlled trial. BMC Anesthesiol 2019; 19:33. [PMID: 30832590 DOI: 10.1186/s12871-019-0703-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 02/25/2019] [Indexed: 12/18/2022] Open
Abstract
Background During an emergency endotracheal intubation, rapid sequence induction intubation (RSII) with cricoid pressure (CP) is frequently implemented to prevent aspiration pneumonia. We evaluated the CVS in endotracheal intubation in RSII with CP, in comparison with a direct laryngoscope (DL). Methods One hundred fifty patients were randomly assigned to one of three groups: the CVS as a video stylet (CVS-V) group, the CVS as a lightwand (CVS-L) group and DL group. Primary outcomes were to assess the power of the CVS, compared with DL, regarding the first attempt success rate and intubation time in simulated RSII with CP. Secondary outcomes were to examine hemodynamic stress response and the incidence of complications. Results The first attempt success rates within 30 s and within 60 s were higher in CVS-V and DL group than those in CVS-L group (p = 0.006 and 0.037, respectively). The intergroup difference for intubation success rate within 30 s was nonsignificant and almost all the patients were successfully intubated within 60 s (98% for CVS-L and DL group, 96% for CVS-L group). Kaplan-Meier estimator demonstrated the median intubation time was 10.6 s [95% CI, 7.5 to 13.7] in CVS-V group, 14.6 s [95% CI, 11.1 to 18.0] in CVS-L group and 16.5 s [95% CI, 15.7 to 17.3] in DL group (p = 0.023 by the log-rank test). However, the difference was nonsignificant after Sidak’s adjustment. The intergroup differences for hemodynamic stress response, sore throat and mucosa injury incidence were also nonsignificant. Conclusions The CVS-D and DL provide a higher first attempt intubation success rate within 30 and 60 s in intubation with CP; the intubation time for the CVS-V was nonsignificantly shorter than that for the other two intubation methods. Almost all the patients can be successfully intubated with any of the three intubation methods within 60 s. Trial registration ClinicalTrials.gov identifier: NCT03841890, registered on February 15, 2019 (retrospectively registered).
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Wan Ibadullah WH, Yahya N, Ghazali SS, Kamaruzaman E, Yong LC, Dan A, Md Zain J. [Comparing insertion characteristics on nasogastric tube placement by using GlideScope™ visualization vs. MacIntosh laryngoscope assistance in anaesthetized and intubated patients]. Braz J Anesthesiol 2016; 66:363-8. [PMID: 27157205 DOI: 10.1016/j.bjan.2016.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 11/11/2014] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVE This was a prospective, randomized clinical study to compare the success rate of nasogastric tube insertion by using GlideScope™ visualization versus direct MacIntosh laryngoscope assistance in anesthetized and intubated patients. METHODS Ninety-six ASA I or II patients, aged 18-70 years were recruited and randomized into two groups using either technique. The time taken from insertion of the nasogastric tube from the nostril until the calculated length of tube had been inserted was recorded. The success rate of nasogastric tube insertion was evaluated in terms of successful insertion in the first attempt. Complications associated with the insertion techniques were recorded. RESULTS The results showed success rates of 74.5% in the GlideScope™ Group as compared to 58.3% in the MacIntosh Group (p=0.10). For the failed attempts, the nasogastric tube was successfully inserted in all cases using rescue techniques. The duration taken in the first attempt for both techniques was not statistically significant; Group A was 17.2±9.3s as compared to Group B, with a duration of 18.9±13.0s (p=0.57). A total of 33 patients developed complications during insertion of the nasogastric tube, 39.4% in Group A and 60.6% in Group B (p=0.15). The most common complications, which occurred, were coiling, followed by bleeding and kinking. CONCLUSION This study showed that using the GlideScope™ to facilitate nasogastric tube insertion was comparable to the use of the MacIntosh laryngoscope in terms of successful rate of insertion and complications.
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Affiliation(s)
- Wan Hafsah Wan Ibadullah
- Departamento de Anestesiologia e Cuidados Intensivos, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malásia
| | - Nurlia Yahya
- Departamento de Anestesiologia e Cuidados Intensivos, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malásia.
| | - Siti Salmah Ghazali
- Departamento Anestesiologia e Cuidados Intensivos, Hospital Kuala Lumpur, Kuala Lumpur, Malásia
| | - Esa Kamaruzaman
- Departamento de Anestesiologia e Cuidados Intensivos, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malásia
| | - Liu Chian Yong
- Departamento de Anestesiologia e Cuidados Intensivos, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malásia
| | - Adnan Dan
- Departamento de Anestesiologia e Cuidados Intensivos, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malásia
| | - Jaafar Md Zain
- Departamento de Anestesiologia e Cuidados Intensivos, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malásia
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Ahmadi K, Ebrahimi M, Hashemian AM, Sarshar S, Rahimi-Movaghar V. GlideScope Video Laryngoscope for Difficult Intubation in Emergency Patients: a Quasi-Randomized Controlled Trial. Acta Med Iran 2015; 53:738-742. [PMID: 26749229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023] Open
Abstract
Macintosh direct laryngoscope has been the most widely used device for tracheal intubation. GlideScope video laryngoscope (GVL) has been recently introduced as an alternative device for performing intubation; however, its validity in emergency settings has not been thoroughly evaluated. The aim of this study was to compare Macintosh direct laryngoscope versus GVL for emergency endotracheal intubation. This quasi-randomized clinical trial was performed on 97 patients referred to Imam Reza Hospital whom all needed emergency intubation in 2011. Patients were divided into two groups of the easy airway and difficult airway; intubation was performed for patients with direct laryngoscopy or GVL. Then, the patients were evaluated in terms of demographic characteristics, successful intubation rate and intubation time. Data was analyzed by SPSS software 16. There was no significant difference in demographic characteristics of the patients in both easy airway and difficult airway groups who intubated with direct laryngoscopy and GVL methods (P>0.05). In difficult airway group, a significant difference was found in successful intubation at the first attempt (60.9% vs. 87.5%; P=0.036), overall intubation time (32.7 ± 14.58 vs. 22.5±7.88; P<0.001) and first attempt intubation time (28.43 ± 12.51 vs. 21.48±7.8; P=0.001) between direct laryngoscopy and GVL. These variables were not significantly different between two methods in easy airway group. According to the results, GVL can be a useful alternative to direct laryngoscopy in emergency situations and especially in cases with a difficult airway.
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Affiliation(s)
- Koorosh Ahmadi
- Department of Emergency Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Mohsen Ebrahimi
- Department of Emergency Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amir Masoud Hashemian
- Department of Emergency Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Saeed Sarshar
- Department of Emergency Medicine, Khorramabad University of Medical Sciences, Khorramabad, Iran
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Wan Ibadullah WH, Yahya N, Ghazali SS, Kamaruzaman E, Yong LC, Dan A, Md Zain J. Comparing insertion characteristics on nasogastric tube placement by using GlideScope™ visualization vs. MacIntosh laryngoscope assistance in anaesthetized and intubated patients. Braz J Anesthesiol 2015; 66:363-8. [PMID: 27343785 DOI: 10.1016/j.bjane.2014.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 11/11/2014] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVE This was a prospective, randomized clinical study to compare the success rate of nasogastric tube insertion by using GlideScope™ visualization versus direct MacIntosh laryngoscope assistance in anesthetized and intubated patients. METHODS Ninety-six ASA I or II patients, aged 18-70 years were recruited and randomized into two groups using either technique. The time taken from insertion of the nasogastric tube from the nostril until the calculated length of tube had been inserted was recorded. The success rate of nasogastric tube insertion was evaluated in terms of successful insertion in the first attempt. Complications associated with the insertion techniques were recorded. RESULTS The results showed success rates of 74.5% in the GlideScope™ Group as compared to 58.3% in the MacIntosh Group (p=0.10). For the failed attempts, the nasogastric tube was successfully inserted in all cases using rescue techniques. The duration taken in the first attempt for both techniques was not statistically significant; Group A was 17.2±9.3s as compared to Group B, with a duration of 18.9±13.0s (p=0.57). A total of 33 patients developed complications during insertion of the nasogastric tube, 39.4% in Group A and 60.6% in Group B (p=0.15). The most common complications, which occurred, were coiling, followed by bleeding and kinking. CONCLUSION This study showed that using the GlideScope™ to facilitate nasogastric tube insertion was comparable to the use of the MacIntosh laryngoscope in terms of successful rate of insertion and complications.
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Affiliation(s)
- Wan Hafsah Wan Ibadullah
- Department of Anaesthesiology and Intensive Care, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Nurlia Yahya
- Department of Anaesthesiology and Intensive Care, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia.
| | - Siti Salmah Ghazali
- Department of Anaesthesiology and Intensive Care, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Esa Kamaruzaman
- Department of Anaesthesiology and Intensive Care, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Liu Chian Yong
- Department of Anaesthesiology and Intensive Care, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Adnan Dan
- Department of Anaesthesiology and Intensive Care, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Jaafar Md Zain
- Department of Anaesthesiology and Intensive Care, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
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