Turkiye Klinikleri Journal of Anesthesiology Reanimation

.: ORIGINAL RESEARCH
Is Awake Videolaryngoscopic Assessment of the Airway a New Tool to Predict the Unpredictable?: A Randomised Crossover Clinical Trial
Havayolunun Uyanık Video Laringoskopik Değerlendirmesi Öngörülmeyeni Öngörmekte Yeni Araç Olabilir mi?: Randomize Çapraz Geçişli Çalışma
Zehra İpek ARSLANa, Funda SEYHANa, Huri YEŞİLDALa
aDepartment of Anesthesiology and Reanimation, Kocaeli University Faculty of Medicine, Kocaeli, TURKEY
Turkiye Klinikleri J Anest Reanim. 2021;19(1):1-7
doi: 10.5336/anesthe.2020-78587
Article Language: EN
Full Text
ABSTRACT
 Objective: Even with worldwide acceptance and obedience to airway evaluation tests, there have not been enough tests performed to predict a difficult intubation with 100% accuracy. The Cochrane database published a review about the insufficiency of airway examination tests. For decades, anesthesiologists have tried to identify these issues. Material and Methods: After ethics committee approval and written informed consent had been obtained, 20 patients were enrolled to this prospective randomised study. All patients were oxygenated before and during the procedure. Standard anesthesia monitoring and 0.05 mg.kg-1 midazolam was administered intravenously. The nasopharynx was prepared with a topical 10% lidocaine spray then a continuous remifentanil infusion was given at a rate of 0.07 μ.kg.min-1 at least for 3 minutes. Awake videolaryngoscopy with Storz C-MAC, Storz D-Blade, McGrath MAC X-Blade and Airtraq was performed in random order to the same patient. Results: Two women denied participation and we analysed 18 patients. One patient did not allow the Airtraq to be inserted deeper and so we had 17 analyses for awake assessment for the Airtraq. Demographic and airway variables of patients were similar. The duration to obtain the optimal view was similar among the videolaryngoscopes. The comfort rating of patient and the observer were lower in the C-MAC (p<0.001). The Cormack-Lehane grades were worse in the C-MAC when compared to the others (p=0.006). Gag reflex occurred more in the Airtraq and the C-MAC videolaryngoscopes (p=0.007). Conclusion: Airtraq, McGrath MAC X-Blade, Storz D-Blade was superior to Storz C-MAC for awake videolaryngoscopic assessment of the airway as a new tool to predict a difficult laryngoscopy.

Keywords: Laryngoscopes; intubation; airway management
ÖZET
 Amaç: Havayolu değerlendirme testleri tüm dünyaca kabul edilmiş ve itaat edilmiş olunmasına rağmen zor havayolunu %100 öngörebilecek yeterli test bulunmamaktadır. Cochrane veri tabanı, havayolu değerlendirme testlerinin yetersizliği ile ilgili derleme yayımlamıştır. Dekatlardan beri anestezistler, bu konuları tanımlamaya çalışmıştır. Gereç ve Yöntemler: Yazılı bilgilendirilmiş hasta onamı ve etik kurul onamı alındıktan sonra bu prospektif randomize çalışmaya 20 hasta dâhil edildi. Tüm hastalar işlem öncesi ve sonrasında oksijene edildi. Standart anestezi monitörizasyonu ve 0,05 mg.kg-1 midazolam intravenöz olarak uygulandı. Nazofarinks, %10 topikal lidokain sprey ile hazırlandıktan sonra en az 3 dk boyunca 0,07 μgr.kg.dk-1 hızda sürekli remifentanil infüzyonu verildi. Storz C-MAC, Storz D-Blade, McGrath MAC X-Blade ve Airtraq ile uyanık video laringoskopi rastgele aynı hastaya uygulandı. Bulgular: İki kadın hasta katılmayı reddetti ve 18 hasta analiz edildi. Bir hasta Airtraq'in derine yerleştirilmesine izin vermedi, böylece uyanık değerlendirmede Airtraq için 17 hasta analizimiz oldu. Hastaların demografik ve havayolu verileri benzerdi. Optimal görüntüyü elde etme zamanı gruplar arasında benzerdi. Hastanın ve gözlemcinin konfor derecelendirmesi C-MAC'de düşüktü (p<0,001). Cormack-Lehane evreleri C-MAC'de diğerlerine kıyasla kötüydü (p=0,006). Krikoid bası ile Cormack-Lehane evreleri video laringoskoplar arasında benzerdi. Airtraq ve C-MAC video laringoskoplarında daha fazla öğürme refleksi gelişti (p=0,007). Sonuç: Zor laringoskopinin öngörülmesinde yeni araç olarak, Airtraq, McGrath MAC X-Blade ve Storz D-Blade, uyanık video laringoskopik değerlendirmede Storz C-MAC'den üstündür.

Anahtar Kelimeler: Laringoskoplar; entübasyon; havayolu yönetimi
REFERENCES:
  1. Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al; American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118(2):251-70.[Crossref] [PubMed] 
  2. Heinrich S, Birkholz T, Irouschek A, Ackermann A, Schmidt J. Incidences and predictors of difficult laryngoscopy in adult patients undergoing general anesthesia : a single-center analysis of 102,305 cases. J Anesth. 2013;27(6):815-21.[Crossref] [PubMed] 
  3. Martin LD, Mhyre JM, Shanks AM, Tremper KK, Kheterpal S. 3,423 emergency tracheal intubations at a university hospital: airway outcomes and complications. Anesthesiology. 2011;114(1):42-8.[Crossref] [PubMed] 
  4. Cook TM, Woodall N, Harper J, Benger J; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth. 2011;106(5):632-42.[Crossref] [PubMed] 
  5. Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al; Difficult Airway Society intubation guidelines working group. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827-48.[Crossref] [PubMed] [PMC] 
  6. Roth D, Pace NL, Lee A, Hovhannisyan K, Warenits AM, Arrich J, et al. Airway physical examination tests for detection of difficult airway management in apparently normal adult patients. Cochrane Database Syst Rev. 2018;5(5):CD008874.[Crossref] [PubMed] [PMC] 
  7. Vannucci A, Cavallone LF. Bedside predictors of difficult intubation: a systematic review. Minerva Anestesiol. 2016;82(1):69-83.[PubMed] 
  8. Yentis SM. Predicting difficult intubation--worthwhile exercise or pointless ritual? Anaesthesia. 2002;57(2):105-9.[Crossref] [PubMed] 
  9. Healy DW, Maties O, Hovord D, Kheterpal S. A systematic review of the role of videolaryngoscopy in successful orotracheal intubation. BMC Anesthesiol. 2012;12:32.[Crossref] [PubMed] [PMC] 
  10. Alhomary M, Ramadan E, Curran E, Walsh SR. Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation: a systematic review and meta-analysis. Anaesthesia. 2018;73(9):1151-61.[Crossref] [PubMed] 
  11. Law JA, Broemling N, Cooper RM, Drolet P, Duggan LV, Griesdale DE, et al, Wong DT; Canadian Airway Focus Group. The difficult airway with recommendations for management--part 1--difficult tracheal intubation encountered in an unconscious/induced patient. Can J Anaesth. 2013;60(11):1089-118.[Crossref] [PubMed] [PMC] 
  12. Kheterpal S, Healy D, Aziz MF, Shanks AM, Freundlich RE, Linton F, et al; Multicenter Perioperative Outcomes Group (MPOG) Perioperative Clinical Research Committee. Incidence, predictors, and outcome of difficult mask ventilation combined with difficult laryngoscopy: a report from the multicenter perioperative outcomes group. Anesthesiology. 2013;119(6):1360-9.[PubMed] 
  13. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-9.[PubMed] 
  14. Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology. 2005;103(2):429-37.[Crossref] [PubMed] 
  15. Nørskov AK, Wetterslev J, Rosenstock CV, Afshari A, Astrup G, Jakobsen JC, et al. Effects of using the simplified airway risk index vs usual airway assessment on unanticipated difficult tracheal intubation-a cluster randomized trial with 64,273 participants. Br J Anaesth. 2016;116(5):680-9.[Crossref] [PubMed] 
  16. Cattano D, Panicucci E, Paolicchi A, Forfori F, Giunta F, Hagberg C. Risk factors assessment of the difficult airway: an italian survey of 1956 patients. Anesth Analg. 2004;99(6):1774-9.[Crossref] [PubMed] 
  17. Nowakowski M, Williams S, Gallant J, Ruel M, Robitaille A. Predictors of Difficult Intubation with the Bonfils Rigid Fiberscope. Anesth Analg. 2016;122(6):1901-6.[Crossref] [PubMed] 
  18. Arslan Zİ, Ozdal P, Ozdamar D, Agır H, Solak M. Nasotracheal intubation of a patient with restricted mouth opening using a McGrath MAC X-Blade and Magill forceps. J Anesth. 2016;30(5):904-6.[Crossref] [PubMed] 
  19. Drenguis AS, Carlson JN. GlideScope vs. C-MAC for Awake Upright Laryngoscopy. J Emerg Med. 2015;49(3):361-8.[Crossref] [PubMed] 
  20. Silverton NA, Youngquist ST, Mallin MP, Bledsoe JR, Barton ED, Schroeder ED, et al. GlideScope versus flexible fiber optic for awake upright laryngoscopy. Ann Emerg Med. 2012;59(3):159-64.[Crossref] [PubMed] 
  21. Türkay M, Şentürk T, Arslan BY, Yeter H, Sevdi MS, Aydın S, et al. Indirect laryngoscopic assessment for the diagnosis of difficult intubation in patients undergoing microlaryngeal surgery. Wien Med Wochenschr. 2016;166(1-2):62-7.[Crossref] [PubMed] 
  22. Rosenblatt W, Ianus AI, Sukhupragarn W, Fickenscher A, Sasaki C. Preoperative endoscopic airway examination (PEAE) provides superior airway information and may reduce the use of unnecessary awake intubation. Anesth Analg. 2011;112(3):602-7.[Crossref] [PubMed] 
  23. Murphy M, Hung O, Launcelott G, Law JA, Morris I. Predicting the difficult laryngoscopic intubation: are we on the right track? Can J Anaesth. 2005;52(3):231-5.[Crossref] [PubMed] 
  24. Law JA, Broemling N, Cooper RM, Drolet P, Duggan LV, Griesdale DE, et al; Canadian Airway Focus Group. The difficult airway with recommendations for management--part 1--difficult tracheal intubation encountered in an unconscious/induced patient. Can J Anaesth. 2013;60(11):1089-118.[Crossref] [PubMed] [PMC] 
  25. Teoh WH, Kristensen MS. Prediction in airway management: what is worthwhile, what is a waste of time and what about the future? Br J Anaesth. 2016;117(1):1-3.[Crossref] [PubMed] [PMC] 
  26. Hung O, Law JA, Morris I, Murphy M. Airway assessment before intervention: what we know and what we do. Anesth Analg. 2016;122(6):1752-4.[Crossref] [PubMed] 

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