Alternative techniques for tracheal intubation

Alternative rigid blade intubation devices available in recent years include the Glidescope, Airtraq and Bonfils laryngoscopes. The Macintosh blade works by displacing the tongue to one side and into the submandibular space while the tip of the device sits in the vallecula lifting the hyoid and so the epiglottis forward to reveal the laryngeal inlet. Under less favourable intubating conditions, the tongue is not accommodated in the submandibular space and tends to be compressed downwards. As a result the vallecula is not accessible and the blade tip is less able to be drawn forward. The retro-molar Bonfils avoids this problem by starting from a posterior position in the mouth and approaching the larynx below and alongside the tongue. The Bonfils also serves as a rigid stylet inside the tracheal tube again producing minimal tongue displacement. Airtraq also compresses the tongue less and usually sits on the posterior pharyngeal wall where it maintains the laryngeal view with a minimum of effort. It houses the tracheal tube in a channel that delivers it into the device's field of view. While better optical systems have tended to improve visualization of the laryngeal inlet, this has not necessarily resulted in easier intubation conditions, shorter intubation times or improved overall success rates. Part of the problem has been that they have limited fields of view compared with the stereoscopic view of tube advancement down to the larynx as afforded by Macintosh.     

Comparaison de l’Airtraq™ et du laryngoscope Macintosh pour l’intubation trachéale chez l’adulte avec stabilisation manuelle en ligne du rachis cervical

Introduction

Airtraq laryngoscope is a new and single use device for endotracheal intubation. Few studies showed the superiority of the Airtraq comparing to Macintosh laryngoscope in the setting of difficult intubation.

Study design

To compare the performance of these two laryngoscopes by simulating a situation of reduced mobility of the cervical spine by applying the Manual in-line stablization (MILS) maneuver.

Patients and methods

After obtaining the approval of the ethic committee, we realized a prospective single blind randomized study. During a 6-month period, 120 consenting patients scheduled for ORL or ophthalmologic surgery were included. They all had general anesthesia and orotracheal intubation. These patients were randomly and equally divided in two groups (n = 60), depending on the type of the laryngoscope used (Airtraq or Macintosh). Were excluded from the study the patients with history or criteria predicting difficult intubation. Each patient was intubated by one of the five experimented anesthetists selected for this work. The principle judgment criteria were: i) the time taken for the orotracheal intubation and ii) the intubation difficulty score (IDS). The secondary judgment criterion was the hemodynamic modifications after the endotracheal intubation.

Results

Demographic and upper airway track variables were comparable between the two groups. There was no case of failure of intubation in this serie. Nonetheless, all the patients of the Airtaq group were intubated from the first attempt, whereas half of the patients of the Macintosh group were intubated after the third attempt. Comparing to the Macintosh, the Airtraq reduces the time taken for the orotracheal intubation (14 ± 1 s vs 19 ± 3 s, P = 0.01), the necessity of additional maneuver to facilitate the intubation, and the intubation difficulty score (0.7 ± 0.3 vs 3.8 ± 1, P < 0.001). Orotracheal intubation using the Airtraq laryngoscope caused less hemodynamic stimulation than using the Macintosh.

Conclusion

Our study showed the usefulness of the Airtraq laryngoscope for endotracheal intubation for patients presenting conditions of difficult intubation such as reduced mobility of the cervical spine.     

Tracheal intubation with size 1 Airtraq in a 3 month old child with occipital meningocele: A novel experience

Meningocele is a neural tube defect where meninges protrude through a skeletal defect. Occipital meningocele compounded with the problems of paediatric airway itself pose challenges to anaesthesiologist in securing and maintaining airway. We present a case report of a 3 month-old-child with occipital meningocele posted for ventriculo-peritoneal shunt for hydrocephalus, who was successfully intubated using a size 1 Airtraq optical laryngoscope.     

Indirect versus direct laryngoscopy for routine nasotracheal intubation

Study Objective

To compare the effectiveness of the indirect laryngoscopes, Airtraq (A) and GlideScope (G), with the Macintosh (M) laryngoscope in routine nasotracheal intubation.

Design

Randomized, single-blinded study.

Setting

University-affiliated, tertiary-care hospital.

Patients

62 adult, ASA physical status 1 and 2 patients with normal airways requiring nasotracheal intubation for dental or maxillofacial surgery.

Intervention

Patients in Groups A and G underwent nasal intubation with the Airtraq and GlideScope, respectively, while laryngoscopy in Group M was performed with the Macintosh blade.

Measurements

Performance of the intubating tools was judged by the ease [Intubation Difficulty Scale (IDS) and numeric rating scale (NRS)] and time to intubation (laryngoscopy and endotracheal tube advancement). In addition, hemodynamic parameters, severity of postoperative sore throat, and posture of the intubator were recorded.

Main Results

IDS score was significantly lower with the Airtraq and GlideScope than with the Macintosh laryngoscope (mean ± SD: A 0.1 ± 0.3, G 0.3 ± 0.6, M 0.8 ± 1.0; P = 0.013). NRS reported by the intubators showed a similar preference for indirect over direct laryngoscopy (A 0.9 ± 0.7, G 1.1 ± 0.6, M 1.9 ± 1.1; P = 0.001). Duration of laryngoscopy and endotracheal tube insertion was similar in all groups. No significant intergroup differences in hemodynamic parameters were recorded. Postoperative sore throat was significantly reduced using the GlideScope compared with the other devices (P = 0.048).

Conclusion

The Airtraq and GlideScope facilitated nasotracheal intubation more so than the Macintosh laryngoscope in adults with apparently normal airways.     

LINX■ reflux management system to bridge the “treatment gap” in gastroesophageal reflux disease: A systematic review of 35 studies

BACKGROUND Gastroesophageal reflux disease(GERD) occurs when the reflux of stomach contents causes troublesome symptoms and/or complications. When medical therapy is insufficient, surgical therapy is indicated and, until now, Laparoscopic fundoplication(LF) constitutes the gold-standard method. However, magnetic sphincter augmentation(MSA) using the LINX^® Reflux Management System has recently emerged and disputes the standard therapeutic approach.AIM To investigate the device’s safety and efficacy in resolving GERD symptoms.METHODS This is a systematic review conducted in accordance to the PRISMA guidelines.We searched MEDLINE, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL databases from inception until September 2019.RESULTS Overall, 35 studies with a total number of 2511 MSA patients were included and analyzed. Post-operative proton-pump inhibitor(PPI) cessation rates reached 100%, with less bloating symptoms and a better ability to belch or vomit in comparison to LF. Special patient groups(e.g., bariatric or large hiatal-hernias)had promising results too. The most common postoperative complication was dysphagia ranging between 6% and 83%. Dilation due to dysphagia occurred in 8% of patients with typical inclusion criteria. Esophageal erosion may occur in up to 0.03% of patients. Furthermore, a recent trial indicated MSA as an efficient alternative to double-dose PPIs in moderate-to-severe GERD.CONCLUSION The findings of our review suggest that MSA has the potential to bridge the treatment gap between maxed-out medical treatment and LF. However, further studies with longer follow-up are needed for a better elucidation of these results.     

Airtraq可视喉镜在经鼻气管插管中的临床研究

目的：探讨Airtraq可视喉镜在经鼻气管插管中的临床应用效果。方法将86例拟接受口腔颌面外科择期手术的患者按数字随机原则分为Airtraq（A）组与Macintosh（M）组各43例,A组在Airtraq可视喉镜下的经鼻气管插管,M组在Mac-intosh喉镜下的经鼻气管插管。结果 A组的插管时间显著短于M组（P〈0.01）,首次插管成功率显著高于M组,组间比较具统计学意义（P〈0.01）;插管前两组患者的各项血流动力学指标比较均无统计学意义（P〉0.05）,插管后血流动力学指标均较插管前升高,但M 组的各项血流动力学指标均较插管前显著升高（P〈0.05）,此外,两组患者在插管后的30min内的 SBP 与DBP均较插管时无明显波动（P〉0.05）,而HR较插管时有增快（P〈0.05）,组间比较又以M组HR增快的程度更为显著（P〈0.05）。结论 Airtraq可视喉镜在经鼻气管插管中具重要临床应用价值,值得进一步推广应用。     

Comparison between Glidescope,Airtraq and Macintosh laryngoscopy for emergency endotracheal intubation in intensive care unit: Randomized controlled trial

Background

Emergency endotracheal intubation in intensive care is a major challenge that can be associated with life-threatening complications. The aim of this study was to evaluate the success of the first attempt of endotracheal intubation and incidence of complications using Macintosh laryngoscopy, Airtraq or Glidescope during emergency intubation in intensive care.

Airtraq®视频喉镜与Macintosh直接喉镜经口气管插管时的血流动力学比较

背景：常规使用Macintosh直接喉镜气管插管可引起强烈的血流动力学反应,从原理上讲,Airtraq®视频喉镜对咽喉刺激小,但两者对血流动力学影响的比较研究尚未见报道。 目的：比较Airtraq®视频喉镜和Macintosh直接喉镜经口气管插管时的血流动力学反应。 设计、时间及地点：随机对照观察,于2008-10/2009-04在大连市第二人民医院麻醉科完成。 对象：40例拟经口气管插管全身麻醉下择期手术患者,按随机数字表法分为Airtraq®视频喉镜组和Macintosh直接喉镜组,每组20例。 方法：麻醉诱导后分别使用Airtraq®视频喉镜和Macintosh直接喉镜显露声门行气管插管。Airtraq®视频喉镜组选择普通型的Airtraq®视频喉镜,置入内径为8.0的气管导管。Macintosh直接喉镜组选用3号镜片,使用内径为8.0的气管导管。 主要观察指标：声门显露时间、导管置入时间、麻醉诱导前、气管插管前、气管插管后即刻、气管插管后1,2,3 min时的收缩压、舒张压、心率,计算各观察时点的二重指数。 结果：Airtraq®视频喉镜组声门显露时间长于Macintosh直接喉镜组(P < 0.01);导管置入时间Airtraq®视频喉镜组短于Macintosh直接喉镜组(P < 0.01)。与麻醉诱导前相比,两组气管插管前收缩压、舒张压、二重指数均明显下降(P < 0.05),心率变化不明显 (P > 0.05)。与气管插管前相比,Airtraq®视频喉镜组插管时及插管后各时点血流动力学指标无明显变化(P > 0.05),Macintosh直接喉镜组气管插管后2 min时心率、二重指数,气管插管后即刻、气管插管后1 min收缩压、舒张压、心率和二重指数显著升高(P < 0.05)。气管插管后即刻、气管插管后1,2 min Macintosh直接喉镜组心率、二重指数显著高于Airtraq®视频喉镜组 (P < 0.05)。 结论：与Macintosh直接喉镜相比,应用Airtraq®视频喉镜行经口气管插管患者血流动力学反应较轻。     

Airtraq可视喉镜在困难气道全麻患者气管插管中的应用

目的观察应用Airtraq可视喉镜对困难气道患者全麻中行气管插管的临床效果。方法选择拟经口气管插管全身麻醉下实施择期手术的困难气道患者60例,MallampatisⅢ～Ⅳ级,随机分为Airtraq组、Macintosh组,每组各30例。两组均采用慢诱导气管插管,诱导后分别采用Airtraq可视喉镜及Macintosh喉镜进行气管插管操作,比较两组气管插管一次成功率、插管时间和麻醉诱导前（T1）、诱导后（T2）、气管插管后即刻（T3）及气管插管后3 min（T4）的HR、SBP、DBP,观察两组声门暴露及并发症情况。结果 Airtraq组气管插管一次成功率高于Macintosh组,插管时间短于Macintosh组,T3、T4时HR、SBP、DBP低于Macintosh组,并发症发生率低于Macintosh组（P均〈0.05）。Airtraq组Ⅰ级气管插管声门暴露的比例高于Macintosh组（P〈0.05）。结论 Airtraq可视喉镜具有快速、声门暴露好、气管插管时血流动力学变化幅度小、插管损伤小的优点,适合于困难气道患者的气管插管。