The intubating laryngeal mask airway with and without fiberoptic guidance

We conducted this feasibility study using the intubating laryngeal mask airway (ILMA) and a polyvinyl chloride tracheal tube to compare success rates, hemodynamic effects, and postoperative morbidity with two methods of tracheal intubation. After ethics approval and informed consent, 90 healthy ASA physical status I or II women with normal airways were enrolled in the randomized, controlled study. After a standardized inhaled anesthesia induction protocol, tracheal intubations using ILMA with fiberoptic guidance (ILMA-FOB) and ILMA inserted blindly without fiberoptic guidance (ILMA-Blind) were compared with the control group of direct laryngoscopy (laryngoscopy group). All 90 patients were successfully ventilated. For tracheal intubation, success rates were equal in all three groups (97%). Total intubation times were longer for the ILMA-FOB group (77 s versus 48.5 s for laryngoscopy and 53.5 s for ILMA-Blind). The laryngoscopy group had a larger increase in mean arterial blood pressure to tracheal intubation. There were no differences in postoperative sore throat or hoarseness among the groups. In conclusion, success rates are equally high for tracheal intubation using ILMA-Blind and ILMA-FOB techniques in women with normal airways. IMPLICATIONS: The intubating laryngeal mask airway (ILMA) can be used as a primary airway for oxygenation and ventilation. Both methods of tracheal intubation using the ILMA were equally successful. Postoperative morbidity in the ILMA groups was similar to that in the laryngoscopy group. For women with normal airways, both the ILMA inserted blindly and the ILMA with fiberoptic guidance are suitable alternatives to laryngoscopy for tracheal intubation.     

Three-dimensional cervical spine movement during intubation using the Macintosh and Bullard laryngoscopes, the bonfils fibrescope and the intubating laryngeal mask airway

BACKGROUND AND OBJECTIVE: Cervical spine movement may be limited for morphological reasons or through injury. The major goal of the present study was to evaluate the three-dimensional cervical spine movement during intubation with a Macintosh or Bullard laryngoscope, a Bonfils fibrescope or an intubating laryngeal mask using an ultrasound-based motion system. METHODS: Forty-eight patients without any history of cervical spine problems who had to undergo elective surgery in general anaesthesia were intubated using a Macintosh or Bullard laryngoscope, a Bonfils fibrescope or an intubating laryngeal mask airway. During intubation, cervical motion as well as overall time to intubation, number of attempts, and postoperative complaints were noted. RESULTS: The range of cervical spine motion during intubation, especially concerning extension, using the Macintosh laryngoscope was much greater (22.5 degrees +/- 9.9 degrees) than using Bullard (3.4 degrees +/- 1.4 degrees), Bonfils (5.5 degrees +/- 5.0 degrees) or intubating laryngeal mask (4.9 degrees +/- 2.1 degrees). Time to intubate the trachea using Bonfils (52.1 +/- 22.0 s) and intubating laryngeal mask (49.8 +/- 18.7 s) were much longer than with Macintosh (18.9 + 7.1s) and Bullard laryngoscope (16.1 + 6.2 s) (significance level: 0.05). CONCLUSIONS: Our findings suggest that the Bullard laryngoscope may be a useful adjunct to intubate patients with cervical spine injuries. In elective situations when time to intubation is not critical Bonfils as well as intubating laryngeal mask airway should also be considered as serious alternatives to direct laryngoscopy.     

Utility of Bullard intubating laryngoscope with a special stylet in two cases of difficult tracheal intubation

The Bullard intubating laryngoscope is useful for cases of difficult tracheal intubation, but a skilled hand is needed to manipulate it. In two cases of difficult tracheal intubation, we used a recently improved Bullard intubating laryngoscope to which a special stylet is attached to introduce an endotracheal tube easily into the larynx. The difficulties of tracheal intubation were caused by micrognathia and trismus in one case and by restriction of neck movement and trismus due to ankylosing spondylitis in the other case. Using the Bullard intubating laryngoscope with the special stylet, intubation was done smoothly in both cases. This improved Bullard intubating laryngoscope is recommended for cases of difficult tracheal intubation.     

Lightwand intubation using the Trachlight™: a brief review of current knowledge

PURPOSE: About 1% to 3% of laryngoscopic intubations can be difficult or impossible. Light-guided intubation has been proven to be an effective, safe, and simple technique. This article reviews current knowledge about the newer version lightwand: the Trachlight (TL). SOURCE: To determine its clinical utility and limitations, we reviewed the current literature (book and journal articles) on the TL since its introduction in 1995. PRINCIPAL FINDINGS: TL has been shown to be useful both in oral and nasal intubation for patients with difficult airways. It may also be useful in "emergency" situations or when direct laryngoscopy or fiberoptic endoscopy is not effective, such as with patients who have copious secretions or blood in the oropharynx. TL can also be used for tracheal intubation in conjunction with other devices (laryngeal mask airway -LMA-, intubating LMA, direct laryngoscopy). However, TL should be avoided in patients with tumours, infections, trauma or foreign bodies in the upper airway. CONCLUSIONS: Based on the clinical reports available, the TL has proven to be a useful option for tracheal intubation. In addition, the device can also be used together with other intubating devices, such as the intubating LMA and the laryngoscope, to improve intubating success rates. A clear understanding of the principle of transillumination of the TL, and an appreciation of its indications, contraindications, and limitations, will improve the effectiveness of the device as well as reducing the likelihood of complications. Finally, regular practice with the TL with routine surgical patients requiring tracheal intubation will further improve intubation success rates.     

difficult airway management: comparison of the bullard laryngoscope with the video-optical intubation stylet

PURPOSE: To evaluate, whether the video-optical intubation stylet (VOIS) was more successful for difficult tracheal intubation than the Bullard laryngoscope (BL). METHODS: An intubation mannequin head was modified so that, using a Macintosh blade size 3, only the epiglottis was visible at direct laryngoscopy, representing a grade III laryngoscopic view. Forty anesthesiologists attempted tracheal intubation using each technique. Tracheal intubation with the Bullard laryngoscope was performed using the attached non-malleable intubating stylet preloaded with an endotracheal tube. The video-optical intubation stylet inserted into an endotracheal tube was used with direct laryngoscopy. During conventional laryngoscopy, the video-view from the stylet tip allowed the tracheal tube to be guided behind the epiglottis into the trachea. Ten attempts with each technique were performed by each anesthesiologist in randomized order. Intubation time, and failed intubation (> 60 sec/esophageal intubation) were recorded. The operators assessed the degree of difficulty of each method using a Likert-scale. RESULTS: Mean intubation time (19.2+/-4.5 sec for the BL and 18.8+/-4.6 sec for the VOIS) was almost the identical. The video-optical intubation stylet was associated with fewer failed intubations (8 vs. 41; P<0.005) and had a lower degree of difficulty (1.7+/-0.65 for the VOIS and 2.6+/-0.74 for the BL; P<0.0001). No correlation was found between the anesthesiologist's experience and mean intubation time, estimated degree of difficulty or number of unsuccessful intubation. CONCLUSION: The video-optical intubation stylet was a more effective and simpler intubation device to facilitate difficult tracheal intubation than the Bullard laryngoscope.     

Comparison of Bullard laryngoscope and short-handled Macintosh laryngoscope for orotracheal intubation in pediatric patients with simulated restriction of cervical spine movements

Aim: To compare time to intubation, time to optimal laryngoscopy, best laryngeal view, and success rate of intubation with pediatric Bullard laryngoscope and short‐handled Macintosh laryngoscope in children being intubated with neck stabilization. Background: Securing airway of a patient with restricted cervical spine movement has been a challenge faced by anaesthesiologists around the world. Macintosh laryngoscope with manual inline stabilization is most commonly used. Bullard laryngoscope is also useful in this situation as minimal neck movement occurs with its use. Methods: Forty patients, ASA I or II, aged 2–10 years, were enrolled in this prospective, controlled, and randomized study. Patients were randomly allocated to one of two groups: Group MB (first laryngoscopy using short‐handled Macintosh laryngoscope followed by pediatric Bullard laryngoscope) and Group BM (first laryngoscopy using pediatric Bullard laryngoscope followed by short‐handled Macintosh laryngoscope) with manual inline stabilization after induction of anesthesia and paralysis. Trachea was intubated orally using the second equipment. Results: Laryngeal view when obtained was always Grade 1 with Bullard laryngoscope (38/38) when compared to Macintosh laryngoscope [Grade 1 (10/40)]. The mean time to laryngoscopy (and intubation) was shorter with Macintosh laryngoscope [15.53 s (38.15 s)] than Bullard laryngoscope [35.21 s (75.71 s)], respectively. Success rate of intubation was higher with Macintosh laryngoscope (100%) when compared to Bullard laryngoscope (70%). Conclusions: Laryngoscopy and intubation is faster using a short‐handled Macintosh laryngoscope with a higher success rate compared to pediatric Bullard laryngoscope in pediatric patients when manual inline stabilization is applied.     

Use of the intubating laryngeal mask in children: an evaluation using video-endoscopic monitoring

BACKGROUND AND OBJECTIVE: The intubating laryngeal mask is designed to act as a ventilatory device and as an aid to blind tracheal intubation in adults. The aim of this study was to evaluate the efficacy of the intubating laryngeal mask for ventilation of the lungs and tracheal intubation in children using video-endoscopic control. METHODS: The handling and efficacy of the size 3 intubating laryngeal mask for tracheal intubation in 80 children weighing > or = 25 kg were assessed under video-endoscopic control. Ease of intubating laryngeal mask insertion, adequacy of lung ventilation through the intubating laryngeal mask and airway sealing pressures were recorded. Tracheal intubation was performed blindly by the intubator, while the supervisor observed the procedure on the video display. If blind intubation failed at the first attempt, the monitor view was used to guide the tracheal tube into the trachea. The success rate and time required for successfully placing the tracheal tube were recorded. RESULTS: Insertion of the intubating laryngeal mask was easy in all children. Lung ventilation through the intubating laryngeal mask was uniformly excellent. Blind tracheal intubation at the first attempt was successful in 53 children (66%) within 18.8 +/- 4.1 s. Twenty-four of the 27 failed blind intubation attempts were successfully intubated with video-endoscopic guidance within 28.6 +/- 9.4 s. Two children required replacing the intubating laryngeal mask, one child had to be intubated conventionally. CONCLUSIONS: The size 3 intubating laryngeal mask provides an airway that is easy to establish in children > or = 25 kg with excellent ventilation conditions and allows blind tracheal intubation at the first attempt with a high success rate. Endoscopic monitoring improves its safety and intubation success rate.     

Difficult tracheal intubation in a patient suspected of malignant hyperthermia

We report anesthetic management of a patient suspected of malignant hyperthermia with difficult tracheal intubation. A 64-year-old man was scheduled for a fixation of humerus bone fractures in prone position. He had a history of difficult tracheal intubation due to masseter spasm, and his niece was suspected to be malignant hyperthermia. Anesthesia was induced with propofol using a target controlled infusion. No muscle relaxant was given and spontaneous breathing was maintained. Trials for tracheal intubation failed whenever using a standard laryngoscope, a bronchofiberscope, a laryngeal mask airway or an intubating laryngeal mask airway. Resecting the epiglottic elevating bar of an intubating laryngeal mask airway enabled fiberoptic tracheal intubation. No symptom suggesting malignant hyperthermia developed.     

The cardiovascular response to insertion of the intubating laryngeal mask airway

Sixty-one patients received a standardised anaesthetic and were randomly assigned to three groups: tracheal intubation via direct laryngoscopy, tracheal intubation via an intubating laryngeal mask airway with immediate removal of the device, and tracheal intubation via an intubating laryngeal mask airway with delayed removal. The cardiovascular response to intubation was of a similar magnitude in all groups, although delayed removal of the intubating laryngeal mask airway was associated with a second pressor response. Norepinephrine changed significantly over time following direct laryngoscopy and following immediate removal of the intubating laryngeal mask airway, but not after delayed removal. The findings of this study do not support using the intubating laryngeal mask instead of direct laryngoscopy purely to decrease the response to intubation.     

Failed tracheal intubation using a laryngoscope and intubating laryngeal mask

PURPOSE: To report unexpected failed tracheal intubation using a laryngoscope and an intubating laryngeal mask, and difficult ventilation via a facemask, laryngeal mask and intubating laryngeal mask, in a patient with an unrecognized lingual tonsillar hypertrophy. CLINICAL FEATURES: A 63-yr-old woman, who had undergone clipping of an aneurysm seven weeks previously, was scheduled for ventriculo-peritoneal shunt. At the previous surgery, there had been no difficulty in ventilation or in tracheal intubation. Her trachea remained intubated nasally for 11 days after surgery. Preoperatively, her consciousness was impaired. There were no restrictions in head and neck movements or mouth opening. The thyromental distance was 7 cm. After induction of anesthesia, manual ventilation via a facemask with a Guedel airway was suboptimal and the chest expanded insufficiently. At laryngoscopy using a Macintosh or McCoy device, only the tip of the epiglottis, but not the glottis, could be seen, and tracheal intubation failed. There was a partial obstruction during manual ventilation through either the intubating laryngeal mask or conventional laryngeal mask; intubation through each device failed. Digital examination of the pharynx, after removal of the laryngeal mask, indicated a mass occupying the vallecula. Lingual tonsillar hypertrophy (1 x 1 x 2 cm) was found to be the cause of the failure. Awake fibrescope-aided tracheal intubation was accomplished. CONCLUSIONS: Unexpected lingual tonsillar hypertrophy can cause both ventilation and tracheal intubation difficult, and neither the laryngeal mask nor intubating laryngeal mask may be helpful in the circumstances.     

A new method for endotracheal intubation with the Bullard laryngoscope]

The Bullard laryngoscope is an anatomically shaped rigid fiber optic instrument designed for indirect laryngoscopy and intubation. It requires no neck extension nor flexion to perform laryngeal intubation. This characteristic is especially useful in the case of difficult airway. The Bullard laryngoscope, however, with which it is easy to visualize the cords, has not been popular yet, because using the intubating forceps mechanism requires a certain amount of skill. The intubation method developed by us with Bullard laryngoscope has been tried on 26 patients with difficult airway and ten patients with normal airway. An endotracheal tube is inserted through nostril, and intubation is performed viewing the tube and larynx during all the processes of intubation. Three kinds of endotracheal tubes, i.e. Magill type plain tubes, styletted tubes, and directional tip tubes, are compared. The method using a directional tip tube (Endotrol) is concluded as the best among them. The Endotrol tube itself has such a suitable shape for nasal intubation that it can be introduced to the larynx with little directional change. Therefore, our method is mastered with a shorter training period than the intubation method with fiber-optic laryngoscopes. In conclusion, our intubation method with the Bullard laryngoscopes using the directional tip tubes (Endotrol) is useful for patients with difficult airways, and is also nontraumatic and easy to perform.     

Management of unexpected difficult airway at a teaching institution over a 7-year period

STUDY OBJECTIVE: To review an anesthesiology department's experience with managing unexpected difficult airways over a 7-year time span. DESIGN: Retrospective review of unexpected difficult airway reporting forms. SETTING: A tertiary care teaching hospital. PATIENTS: 447 patients who had an unanticipated difficult airway and had a difficult airway form filled out by their anesthesiologist. MEASUREMENTS: Retrospective identification of pertinent physical features associated with difficult intubation was noted. The techniques chosen, their success, and the frequency with which the different advanced airway techniques were chosen was reviewed. MAIN RESULTS: An anterior larynx was the most common anatomical feature associated with difficult laryngoscopy. When a laryngeal mask airway was placed in our patients, ventilation was possible in all patients. Intubation was successfully "blindly" achieved (ie, without the use of a fiberoptic bronchoscope) through the laryngeal mask airway in 52% of these patients. Fiberoptic intubation was unsuccessful in intubating approximately 10% of patients. The Bullard laryngoscope was the most common advanced airway technique chosen at our institution. CONCLUSION: Mastery with a number of advanced airway techniques should be sought, as multiple modalities may be needed when faced with managing an unexpectedly difficult airway. Formal written communication to the patient of an unexpected difficult airway encounter may allow future anesthesiologists to formulate an appropriate plan for patient care.     

Left molar approach improves laryngeal view in patients with simulated limitation of cervical movements

Background: Immobilized cervical spine, because of either diseases or stabilizing devices, poses considerable difficulties with endotracheal intubation due to poor laryngoscopic view. The left molar (LM) approach has been shown to be useful in difficult sporadic intubation cases. We evaluated efficacy of this approach of laryngoscopy to improve laryngeal view in patients with simulated limitation of cervical movements.
Methods: Thirty patients of American Society of Anesthesiologists grade I/II, who were scheduled to undergo routine surgical procedures under general anaesthesia and endotracheal intubation, were studied. A two-piece semi-rigid cervical collar was used to immobilize the cervical spine. Under standardized anaesthesia and neuromuscular blocking agent, conventional laryngoscopy using a curved Macintosh blade was performed and glottic view was recorded with and without optimal external laryngeal manipulation (OELM). Subsequently, in the same subjects the laryngoscope blade was withdrawn and re-inserted through the LM approach and glottic view was recorded with and without OELM followed by tracheal intubation.
Results: With the conventional approach, laryngeal view was recorded as grade II in five patients, grade III in 24 patients, and grade IV in one patient. However, with the LM approach, laryngeal view was grade I in 25 patients, grade II in five patients, and grade III or IV in none ( P <0.001). Tracheal intubation with the LM approach required the use of a flexible stylet to guide the tube tip into the larynx.
Conclusions: The laryngeal view is improved by the LM approach in patients with simulated limited cervical movements with a high success rate of tracheal intubation, but requires orientation for negotiation of the tube through the narrow oropharyngeal space available.     

Cervical Spine Movement during Laryngoscopy with the Bullard, Macintosh, and Miller Laryngoscopes

Background: Direct laryngoscopy requires movement of the head, neck, and cervical spine. Spine movement may be limited for anatomic reasons or because of cervical spine injury. The Bullard laryngoscope, a rigid fiberoptic laryngoscope, may cause less neck flexion and head extension than conventional laryngoscopes. The purpose of this study was to compare head extension (measured externally), cervical spine extension (measured radiographically), and laryngeal view obtained with the Bullard, Macintosh, and Miller laryngoscopes.

Methods: Anesthesia was induced in 35 ASA 1-3 elective surgery patients. Patients lay on a rigid board with head in neutral position. Laryngoscopy was performed three times, changing between the Bullard, Macintosh, and Miller laryngoscopes. Head extension was measured with an angle finder attached to goggles worn by the patient. The best laryngeal view with each laryngoscope was assessed by the laryngoscopist. In eight patients, lateral cervical spine radiographs were taken before and during laryngoscopy with the Bullard and Macintosh blades.

Results: Median values for external head extension were 11 degrees, 10 degrees, and 2 degrees with the Macintosh, Miller, and Bullard laryngoscopy (P < 0.01), respectively. Significant reductions in radiographic cervical spine extension were found for the Bullard compared to the Macintosh blade at the atlantooccipital joint, atlantoaxial joint, and C3-C4. Median atlantooccipital extension angles were 6 degrees and 12 degrees for the Bullard and Macintosh laryngoscopes, respectively. The larynx could be exposed in all patients with the Bullard but only in 90% with conventional laryngoscope (P < 0.01).     

Fibreoptic assessment of laryngeal aperture in patients with difficult laryngoscopy

PURPOSE: To determine the relationship between the area of the laryngeal aperture (LA) seen fibreoptically during laryngoscopy and the difficulty of tracheal intubation in patients with difficult laryngoscopy METHODS: In 587 adult patients after induction of general anesthesia and muscle relaxation, the best laryngoscopic view of the larynx using a Macintosh 3 blade was classified according to Cormack. When the LA could not be seen, with laryngoscope blade in place, the LA view provided by a fibreoptic bronchoscope (FOB)-camera passed nasally was photographed. Then, the laryngoscopist attempted to intubate the trachea using the Macintosh blade. Tracheal intubation requiring more than three attempts was defined as difficult. After the third attempt, the trachea was intubated orally aided by FOB. The LA view after jaw thrust during FOB-aided intubation was photographed. RESULTS: Laryngoscopy was difficult in 17 of 587 patients. In four, intubation was difficult. In the remaining 13 patients the trachea was easy to intubate. The LA area obtained by the FOB in the difficult group (median, 0.19; intra-quartile range, 0.14 to 0.39 cm2) was smaller than that in the easy group (2.43; 1.84 to 2.93 cm2)(P = 0.003). In contrast, the LA area provided by jaw thrust during the FOB-aided intubation in the difficult group (2.28; 1.99 to 2.73 cm2) was similar to that during laryngoscopy in the easy group. CONCLUSION: Inability of the laryngoscope to provide an adequate LA view is one cause of difficult intubation with the Macintosh laryngoscope in patients with difficult laryngoscopy.     

Fibreoptic views through the laryngeal mask and the intubating laryngeal mask.

BACKGROUND AND OBJECTIVE: The intubating laryngeal mask (intubating laryngeal mask airway) was designed to facilitate blind intubation. Its value as an adjunct to fibreoptic laryngoscopy has not been evaluated. This study compares the intubating laryngeal mask airway with the standard laryngeal mask airway as conduits for fibreoptic laryngoscopy. METHODS: The fibreoptic view of the laryngeal inlet was graded via both devices in 60 anaesthetized patients. The fibreoptic view through the intubating laryngeal mask airway was assessed after the central epiglottic elevator bar had been lifted out of the field of vision by an 8-mm Euromedical tracheal tube, which was inserted to a depth of 18 cm. The fibreoptic view from the aperture bars of the laryngeal mask was recorded. RESULTS: The vocal cords were viewed less frequently through the intubating laryngeal mask airway (52%) than through the laryngeal mask airway (92%) [difference = 40% (95% CI = 26% to 54%), P < 0.0001]. CONCLUSION: The view of the laryngeal inlet is better through the laryngeal mask airway than through a tracheal tube inserted to 18 cm in the intubating laryngeal mask.     

Tracheal intubation and cervical spine excursion: direct laryngoscopy vs. intubating laryngeal mask

Until recently, the most appropriate technique of intubating a patient with a cervical spine injury has been the subject of debate. Tracheal intubation by means of the intubating laryngeal mask (Fastrach), a modified conventional laryngeal mask airway, seems to require less neck manipulation. The aim of this study was to compare the excursion of the upper cervical spine during tracheal intubation using direct laryngoscopy with that during intubation via the laryngeal mask (Fastrach), by examination of lateral cervical spine radiographs in healthy young patients. The intubating laryngeal mask (Fastrach) caused less extension (at C1-2 and C2-3) than intubation by direct laryngoscopy. Direct laryngoscopy is still the fastest method to secure an airway provided no intubating difficulties are present. However, in trauma patients requiring rapid sequence induction and in whom cervical spine movement is limited or undesirable, the intubating laryngeal mask (Fastrach) is a safe and fast method by which to secure the airway.     

Hemodynamic responses to tracheal intubation with laryngoscope versus lightwand intubating device (Trachlight) in adults with normal airway

Lightwand devices are effective and safe as an aid to tracheal intubation. Theoretically, avoiding direct-vision laryngoscopy could allow for less stimulation by intubation than the conventional laryngoscopic procedure. We designed this prospective randomized study to assess the cardiovascular changes after either lightwand or direct laryngoscopic tracheal intubation in adult patients anesthetized with sevoflurane. Sixty healthy adult patients with normal airways were randomly assigned to one of three groups according to intubating procedure under sevoflurane/nitrous oxide anesthesia (fraction of inspired oxygen = 0.33) (n = 20 each). The lightwand group received tracheal intubation with Trachlight, the laryngoscope-intubation group received tracheal intubation with a direct-vision laryngoscope (Macintosh blade), and the laryngoscopy-alone group received the laryngoscope alone. Heart rate and systolic blood pressure were recorded continuously for 5 min after tracheal intubation or laryngoscopy with enough time to intubate. All procedures were successful on the first attempt. The maximum heart rate and systolic blood pressure values obtained after intubation with Trachlight (114 +/- 20 bpm and 143 +/- 30 mm Hg, respectively) did not differ from those with the Macintosh laryngoscope (114 +/- 20 bpm and 138 +/- 23 mm Hg), but they were significantly larger than those in the laryngoscopy-alone group (94 +/- 19 bpm and 112 +/- 21 mm Hg) (P < 0.05). Direct stimulation of the trachea appears to be a major cause of the hemodynamic changes associated with tracheal intubation. IMPLICATIONS: The magnitude of hemodynamic changes associated with tracheal intubation with the Trachlight is almost the same as that which occurs with the direct laryngoscope. Hemodynamic changes are likely to occur because of direct tracheal irritation rather than direct stimulation of the larynx.     

A comparison of the Bullard laryngoscope versus the flexible fiberoptic bronchoscope during intubation in patients afforded inline stabilization

STUDY OBJECTIVE: To compare the Bullard laryngoscope (BL) with the flexible fiberoptic bronchoscope (FFB) in a cervical spine injury model, using inline stabilization. DESIGN: Randomized clinical trial. SETTING: Main operating room of a tertiary care hospital. PATIENTS: 50 adult, ASA physical status I, II, and III patients undergoing an elective general anesthetic. INTERVENTIONS: Each patient's trachea was intubated with both techniques. Cricoid pressure was applied to half of the study patients. MEASUREMENTS: The time for laryngoscopic view and the time to intubation were recorded for each technique. The effects of cricoid pressure on laryngoscopic view and intubation time were determined. MAIN RESULTS: The times for laryngoscopy and intubation were longer in the FFB group than in the BL group (p < 0.004). There was a significantly lower success rate of laryngoscopy view in the FFB group in the presence of cricoid pressure (15 of 25 patients, or 60%) than either of the BL groups or the FFB no-cricoid pressure group. CONCLUSIONS: The BL is more reliable, quicker, and more resistant to the effects of cricoid pressure than is the FFB.     

Teaching with a video system improves the training period but not subsequent success of tracheal intubation with the Bullard laryngoscope

BACKGROUND: The Bullard laryngoscope is useful for the management of a variety of airway management scenarios. Without the aid of a video system, teaching laryngoscopy skills occurs with indirect feedback to the instructor. The purpose of this study was to determine if use of a video system would speed the process of learning the Bullard laryngoscope or improve the performance (speed or success) of its use. METHODS: Thirty-six anesthesia providers with no previous Bullard laryngoscope experience were randomly divided into two groups: initial training (first 15 intubations) with looking directly through the eyepiece (n = 20), or with the display of the scope on a video monitor (n = 16). The subjects each then performed 15 Bullard intubations by looking directly through the eyepiece. RESULTS: There was not an overall significant difference in laryngoscopy or intubation times between the groups. When only the first 15 intubations were considered, the laryngoscopy time was shorter in the video group (26 +/- 24) than in the nonvideo group (32 +/- 34; P< 0.04). In the first 15 patients, there were fewer single attempts at intubation (67.9% vs 80.3%; P< 0.002) and more failed intubations (17.2% vs 6.0%; P< 0.0001) in the nonvideo group. CONCLUSIONS: In conclusion, the authors have shown that use of a video camera decreases time for laryngoscopic view and improves success rate when the Bullard laryngoscope is first being taught to experienced clinicians. However, these benefits are not evident as more experience with the Bullard laryngoscope is achieved, such that no difference in skill with the Bullard laryngoscope is discernible after 15 intubations whether a video system was used to teach this technique.