The effect of the jaw‐thrust manoeuvre on the ability to advance a tracheal tube over a bronchoscope during oral fibreoptic intubation

During fibreoptic intubation, it is often difficult to advance a tracheal tube over the fibreoptic bronchoscope. We performed a prospective randomised study to investigate the effect of the jaw‐thrust manoeuvre on the ability to advance a tracheal tube during oral fibreoptic intubation. After placing the bronchoscope in the trachea, an assistant randomly applied a jaw‐thrust manoeuvre (jaw‐thrust group) or sham manoeuvre (control group) in 82 patients during tube advancement. The jaw‐thrust group had a higher success rate on the first attempt (70.7% vs 34.1%, p = 0.002), required fewer attempts (median (IQR [range]) 1 (1–2 [1–3]) vs 2 (1–3 [1–4]), p < 0.001), and took less time [6 (4–8 [2–16]) s vs 10 (7–15 [3–40]) s, p < 0.001] for tube advancement compared with the control group. The jaw‐thrust manoeuvre facilitates the advancement of a tracheal tube over the bronchoscope during oral fibreoptic intubation.     

A comparison of direct laryngoscopy and jaw thrust to aid fibreoptic intubation

We compared two manoeuvres, jaw thrust and laryngoscopy, to open the airway during fibreoptic intubation in 50 patients after induction of anaesthesia in a crossover study. Patients were randomly allocated to receive either jaw thrust or conventional Macintosh laryngoscopy first. Airway clearance was assessed at both the soft palate and the epiglottis. Direct laryngoscopy provided significantly better airway clearance at the level of the soft palate than jaw thrust (44 (88%) vs 31 (62%), respectively; p = 0.002). At the level of the larynx, airway clearance was equally good in both groups (45 (90%) vs 46 (92%), respectively; p = 0.56). The times to view the larynx (median (interquartile range [range]) 4 (3-5 [2-35]) s vs 3 (3-4 [2-8]) s, respectively) and intubation time (20 (17-23 [11-83]) s vs 18 (15-20 [11-28]) s, respectively) were also similar.     

A comparison of the BURP and conventional and modified jaw thrust manoeuvres for orotracheal intubation using the Clarus Video System

We evaluated the effects of three airway manipulation manoeuvres: (a) conventional (single‐handed chin lift); (b) backward, upward and right‐sided pressure (BURP) manoeuvre; and (c) modified jaw thrust manoeuvre (two‐handed aided by an assistant) on laryngeal view and intubation time using the Clarus Video System in 215 patients undergoing general anaesthesia with orotracheal intubation. In the first part of this study, the laryngeal view was recorded as a modified Cormack–Lehane grade with each manoeuvre. In the second part, intubation was performed using the assigned airway manipulation. The primary outcome was the time to intubation, and the secondary outcomes were the modified Cormack–Lehane grade, the number of attempts and the overall success rate. There were significant differences in modified Cormack–Lehane grade between the three airway manipulations (p < 0.0001). Post‐hoc analysis indicated that the modified jaw thrust improved the laryngeal view compared with the conventional (p < 0.0001) and the BURP manoeuvres (p < 0.0001). The BURP worsened the laryngeal view compared with the conventional manoeuvre (p = 0.0132). The time to intubation in the modified jaw thrust group was shorter than with the conventional manoeuvre (p = 0.0004) and the BURP group (p < 0.0001). We conclude that the modified jaw thrust is the most effective manoeuvre at improving the laryngeal view and shortening intubation time with the Clarus Video System.     

Cardiovascular responses following laryngoscope assisted, fibreoptic orotracheal intubation

The Macintosh laryngoscope has recently been used successfully as an airway clearance device during fibreoptic intubation in patients who presented difficult intubation, but it is not known whether this approach will increase the pressor response to intubation. The aim of this investigation was to compare the cardiovascular responses of this method of facilitating airway clearance with the lingual traction plus jaw thrust method. 40 ASA I or II adult patients were given a standardised general anaesthetic and were randomly allocated to receive either lingual traction with jaw thrust (lingual traction group) or direct laryngoscopy with a Macintosh laryngoscope (laryngoscopy group) as the airway clearance manoeuvre prior to fibreoptic orotracheal intubation. Following intubation there was a significant rise in arterial pressure above pre-induction levels in both groups (p < 0.05); however, the arterial pressure in the laryngoscopy group was significantly greater than that in the lingual traction group (systolic: p = 0.031, diastolic: p = 0.002). It appears therefore that the mechanical stimulus of the Macintosh laryngoscopy evokes a greater pressor response than that of lingual traction plus jaw thrust when these interventions are followed by fibreoptic intubation.     

A comparison of fibreoptic‐guided tracheal intubation through the Ambu®Aura‐i™, the intubating laryngeal mask airway and the i‐gel™: a manikin study

We compared the Aura‐i ^? , intubating laryngeal mask airway and i‐gel ^? as conduits for fibreoptic‐guided tracheal intubation in a manikin. Thirty anaesthetists each performed two tracheal intubations through each device, a total of 180 intubations. The median (IQR [range]) time to complete the first intubation was 40 (31–50 [15–162]) s, 37 (34–48 [25–75]) s and 28 (22–35 [14–59]) s for the Aura‐i, intubating laryngeal mask airway and i‐gel, respectively. Tracheal intubation through the i‐gel was the quickest (p < 0.01). Resistance to railroading of the tracheal tube over the fibrescope was significantly greater through the Aura‐i compared with the intubating laryngeal mask airway and the i‐gel (p = 0.001). There were no failures to intubate through the intubating laryngeal mask airway or the i‐gel but six intubation attempts through the Aura‐i were unsuccessful, in five owing to a railroading failure and in one owing to accidental oesophageal intubation. We conclude that the Aura‐i does not perform as well as the intubating laryngeal mask airway or the i‐gel as an adjunct for performing fibreoptic‐guided tracheal intubation.     

Manoeuvres used to clear the airway during fibreoptic intubation

Fibreoptic orotracheal endoscopy under general anaesthesia maybe more difficult to perform if the upper airway cannot be fullycleared. We have studied the effectiveness of jaw thrust, lingualtraction and the application of both manoeuvres simultaneously,in opening up the orolaryngeal airspace in 30 ASA group 1 or2 patients aged between 16 and 70 yr undergoing elective generalsurgery requiring orotracheal intubation. Airway clearance wasassessed fibreoptically at soft palate level by observing whetheror not the uvula or soft palate was apposed to the base of thetongue, and at epiglottic level by observing whether or notthe epiglottis was apposed to the posterior pharyngeal wall.Lingual traction with Duval’s forceps cleared the tongueaway from the uvula and soft palate significantly more timesthan did jaw thrust (P<0.05). Jaw thrust cleared the epiglottisaway from the posterior pharyngeal wall more frequently thandid lingual traction (P=0.052). Applying both jaw thrust andlingual traction simultaneously cleared the airway at both softpalate and epiglottic level in every patient. When used alone,jaw thrust and lingual traction fail to produce full airwayclearance in a significant number of patients. Combined jawthrust and lingual traction clears the airway more effectivelybut requires two assistants. Br J Anaesth 2001; 87: 207–11     

A randomised comparison of free‐handed vs air‐Q™ assisted fibreoptic‐guided tracheal intubation in children < 2 years of age

We prospectively compared free‐handed and air‐Q? assisted fibreoptic‐guided tracheal intubation in children < 2 years of age. Eighty healthy children were enrolled and randomly assigned to a technique (free‐handed or air‐Q assisted) and operator (trainee or attending). Time, number of attempts and manoeuvres required were assessed. There was no difference in median (IQR [range]) time to successful tracheal intubation between the free‐handed (52.2 (34.8–67.7 [19.7–108.0]) s), and the air‐Q assisted (60.3 (45.5–75.1 [28.1–129.0]) s; p = 0.13) groups, or the number of attempts needed. The air‐Q assisted group required fewer manoeuvres to optimise the laryngeal view (median (IQR [range]) 0 (0–1 [0–2])) than the free‐handed group (1 (1–1 [0–3]); p < 0.001). In conclusion, fibreoptic‐guided tracheal intubation times were similar with and without the use of the air‐Q, but supraglottic airway devices may be a consideration for their other practical advantages.     

Comparison of VivaSight double‐lumen tube with a conventional double‐lumen tube in adult patients undergoing video‐assisted thoracoscopic surgery

The efficiency of a double‐lumen tube depends on its position in the airways, which can be verified by fibreoptic bronchoscopy. The VivaSight DL is a single‐use double‐lumen tube with a camera embedded in the tube's right side. The view from the camera appears continuously on a monitor. In this prospective study of 71 adult patients, we compared intubation times using either the VivaSight DL or a conventional double‐lumen tube. Median (IQR [range]) duration of intubation with visual confirmation of tube position was significantly reduced using the VivaSight DL compared with the conventional double‐lumen tube (51 (42–60 [35–118]) s vs 264 (233–325 [160–490]) s, respectively, p < 0.0001). None of the patients allocated to the VivaSight DL required fibreoptic bronchoscopy during intubation or surgery. The VivaSight DL enables significantly more rapid intubation compared with the conventional double‐lumen tube.     

A comparison of an anterior jaw lift manoeuvre with the Berman airway for assisting fibreoptic orotracheal intubation

This study compared the efficacy of an anterior jaw lift manoeuvre with that of the Berman airway in clearing the upper airway during oral fibreoptic tracheal intubation in anaesthetised, paralysed patients. Fifty patients were randomly assigned to undergo fibreoptic-assisted intubation with one method, followed by crossover to the alternative method. The time taken to view the vocal cords was the primary endpoint, and we also noted the rate of failure to view the cords, i.e. cords not seen after 120 s of endoscopy. Anterior jaw lift yielded significantly shorter times to view the vocal cords (median [interquartile range; range]: 22 [17-46; 7-120] s vs 40 [29-67; 21-120] s, p = 0.001) and a higher success rate (49/50 vs 42/50, p = 0.014). We conclude that the anterior jaw lift is more effective than the Berman device for achieving airway clearance in this setting.     

Stylet‐ or forceps‐guided tube exchanger to facilitate GlideScope® intubation in simulated difficult intubations – a randomised controlled trial

The GlideScope^® videolaryngoscope is widely used in the management of the difficult airway. However, passing the tracheal tube through the vocal cords can be awkward, and the use of a stylet to guide insertion is recommended. This randomised controlled trial evaluated a forceps‐guided tube exchanger as an alternative to the stylet to aid intubation with the GlideScope in patients undergoing anaesthesia, with a simulated difficult airway created by the application of a semi‐rigid cervical collar. Data were analysed from 178 patients randomly assigned to undergo intubation using either the stylet (n = 88) or a forceps‐guided tube exchanger (n = 90). All intubations were completed successfully, with first attempt rates of 93.2% using the stylet and 94.4% using the exchanger (p = 0.597). The mean (SD) intubation time was 67.8 (28.7) s in the stylet group and 66.1 (15.5) s in the forceps‐guided tube exchanger group (p = 0.11). The frequency of sore throat 1 h after extubation was 34.1% in the stylet group and 2.2% in the tube exchanger group (p < 0.001); 24 h after extubation the corresponding figures were 40.0% and 11.1% (p < 0.001). Using a forceps‐guided tube exchanger may offer an advantage over a stylet in guiding tracheal intubation when the GlideScope is used.     

Choice of anaesthesia for category‐1 caesarean section in women with anticipated difficult tracheal intubation: the use of decision analysis

A predicted difficult airway is sometimes considered a contra‐indication to rapid sequence induction of general anaesthesia, even in an urgent case such as a category‐1 caesarean section for fetal distress. However, formally assessing the risk is difficult because of the rarity and urgency of such cases. We have used decision analysis to quantify the time taken to establish anaesthesia, and probability of failure, of three possible anaesthetic methods, based on a systematic review of the literature. We considered rapid sequence induction of general anaesthesia with videolaryngoscopy, awake fibreoptic intubation and rapid spinal anaesthesia. Our results show a shorter mean (95% CI) time to induction of 100 (87–114) s using rapid sequence induction compared with 9 (7–11) min for awake fibreoptic intubation (p < 0.0001) and 6.3 (5.4–7.2) min for spinal anaesthesia (p < 0.0001). We calculate the risk of ultimate failed airway control after rapid sequence induction to be 21 (0–53) per 100,000 cases, and postulate that some mothers may accept such a risk in order to reduce potential fetal harm from an extended time interval until delivery. Although rapid sequence induction may not be the anaesthetic technique of choice for all cases in the circumstance of a category‐1 caesarean section for fetal distress with a predicted difficult airway, we suggest that it is an acceptable option.     

The triple airway manoeuvre for insertion of the laryngeal mask airway in paralyzed patients

The efficacy of the triple airway manoeuvre (mouth opening, head extension and jaw thrust) for insertion of the laryngeal mask airway (LMA) was compared with the standard insertion method. One hundred paralyzed patients were allocated randomly into two groups: in the control group (n = 50) the LMA was inserted by the standard method, and in the other (TAM group, n = 50) by the triple airway manoeuvre. In ten patients of each group, the position of the LMA and the epiglottis was assessed radiographically before insertion, after insertion but before cuff inflation, and after cuff inflation. In all patients the position was examined using fibrescopy before and after cuff inflation. The mean distance between the epiglottis and the posterior pharyngeal wall, measured radiographically before LMA insertion, was greater in the TAM group (16.3 (SD 4.3) mm) than in the control group (7.0 (2.8) mm) (P < 0.001). Before cuff inflation, radiography and fibrescopy showed that the LMA compressed the epiglottis downwards more frequently in the control group. After cuff inflation the glottis was completely visible fibreoptically in 66% in the TAM group, compared with 14% in the control group (P < 0.001). Complete downfolding of the epiglottis was seen in 10% in the control group and none in the TAM group (P < 0.05). We conclude that in paralyzed patients LMA insertion with the triple airway manoeuvre provides wider pharyngeal space and decreases the incidence of epiglottic downfolding by the LMA compared with the standard method.     

A comparison of a flexometallic tracheal tube with the intubating laryngeal mask tracheal tube for nasotracheal fibreoptic intubation using the two‐scope technique*

We compared the incidence and site of impingement of a flexometallic tracheal tube with those of the re‐usable intubating laryngeal mask (ILMA) tube in 60 anaesthetised patients undergoing nasotracheal fibreoptic intubation for oral surgery. A two‐scope technique was used, observing the site of impingement with one scope whilst intubating with the other. The tubes were 6.0‐mm in females and 6.5‐mm in males. Impingement occurred with 10 (33%) flexometallic and 2 (7%) ILMA tubes (p < 0.032). In all but one case, the impingement was posterior to the right arytenoid cartilage. When impingement was observed, a single disempaction with a 90° anticlockwise rotational manoeuvre overcame impingement in every case except one, allowing successful intubation. We conclude that the incidence of impingement of the tracheal tube, and therefore of potential laryngeal trauma from nasotracheal fibreoptic intubation, is significantly greater with the flexometallic tube than with the ILMA tube.     

Fibreoptic vs videolaryngoscopic (C‐MAC® D‐BLADE) nasal awake intubation under local anaesthesia

Numerous indirect laryngoscopes have been introduced into clinical practice and their use for tracheal intubation under local anaesthesia has been described. However, a study comparing indirect laryngoscopic vs fibreoptic intubation under local anaesthesia and sedation appears lacking. Therefore, we evaluated both techniques in 100 patients with an anticipated difficult nasal intubation time for intubation the primary outcome. We also assessed success rate, glottic view, Ramsey score, and patients' and anaesthetists' satisfaction. The median (IQR [range]) time for intubation was significantly shorter with the videolaryngoscope with 38 (24–65 [11–420]) s vs 94 (48–323 [19–1020]) s (p < 0.0001). There was no difference in the success rate of intubation (96% for both techniques; p > 0.9999) and satisfaction of the anaesthetists and patients. We conclude that in anticipated difficult nasal intubation a videolaryngoscope represents an acceptable alternative to fibreoptic intubation.     

A systematic review and meta‐analysis of the i‐gel® vs laryngeal mask airway in children

We systematically reviewed randomised controlled trials of the i‐gel^® vs different types of laryngeal mask airway in children. We included nine studies. There was no evidence for differences in: rate of insertion at first attempt; insertion time; ease of insertion; or gastric tube insertion. The mean (95% CI) oropharyngeal leak pressure was 3.29 (2.25–4.34) cmH₂O higher with the i‐gel, p < 0.00001. The relative rate (95% CI) of a good fibreoptic view through the i‐gel was 1.10 (1.01–1.19), p = 0.02. There were no significant differences in the rates of complications, except for blood on the airway, relative rate with the i‐gel 0.46 (0.23–0.91), p = 0.02. We concluded that the clinical performance of the i‐gel and LMA was similar, except for three outcomes that favoured the i‐gel.     

Management der oberen Atemwege beim spontan atmenden Kind

In unconscious, spontaneously breathing and anaesthetised children, a high incidence of partial or complete airway obstruction jeopardizes sufficient oxygenation. In this situation, the most important and efficient manoeuvre is to open up the upper airway. Chin lift, jaw thrust and continuous positive airway pressure (CPAP) are proven and effective methods for opening an obstructed upper airway. In addition to these simple airway manoeuvres, different techniques of body positioning (e.g., lateral positioning or supine position in combination with the "sniffing position") are effective to improve and maintain upper airway patency.     

Pre‐oxygenation in healthy volunteers: a comparison of the supine and 45° seated positions*

Pre‐oxygenation in the seated (sitting) position has been associated with better oxygenation. This randomised, cross over study compared oxygenation in the supine position with that in the 45° seated position in 40 young, healthy volunteers. Oxygen was administered through a circle system and tight fitting facemask. Transcutaneous Po ₂ levels were recorded at 10‐s intervals from two measurement points during 4 min of oxygenation in the two positions. The mean (SD) values of 12 measurements taken between the third and fourth minute were recorded. There was no difference in the increase in tissue oxygenation when comparing the supine and seated positions (32.7 (7.3) vs 32.6 (6.7) kPa, respectively). We conclude that there is no evidence that pre‐oxygenation in the 45° seated position improves tissue oxygenation in young healthy volunteers compared with the supine position.     

Assessment of manoeuvres required for successful blind tracheal intubation through the PAXpress

A PAXpress^™ (Vital Signs Inc., Barnham, UK) airway device was placed in 50 adult ASA grade I and II patients undergoing elective surgery under general anaesthesia. The alignment of the PAXpress to the larynx was scored fibreoptically. The patients were then intubated blindly through the PAXpress and the adjusting manoeuvres required for successful intubation and complications of intubation observed. Insertion of the PAXpress was successful in all patients, and intubation was successful in 42 (84%) patients. Eleven patients were intubated in the neutral position, seven with a flexion manoeuvre and 24 with an extension manoeuvre. Intubation was successful in 17/20, 18/20, 6/8 and 1/2 of patients with a fibreoptic alignment score of 1, 2, 3 and 4, respectively. When the fibreoptic alignment score was between 2 and 4 intubation was achieved predominantly with the extension manoeuvre (20/30, 66%) rather than the flexion manoeuvre (1/30, 3%) or the neutral position (5/30, 16%). Blood staining was observed in 20 patients. We conclude that blind tracheal intubation through PAXpress has a moderately good success rate and a high incidence of mucosal trauma. 'Extension' is the predominant adjusting manoeuvre required for blind tracheal intubation, especially when the alignment of the PAXpress to the larynx is poor.     

A randomised,non‐crossover study of the GuardianCPV™ Laryngeal Mask versus the LMA Supreme™ in paralysed,anaesthetised female patients

We investigated the hypothesis that the oropharyngeal leak pressure would differ between the GuardianCPV? and the LMA Supreme? in anaesthetised patients. We randomly assigned 120 patients to receive either the GuardianCPV or the LMA Supreme for airway management. Oropharyngeal leak pressure was measured during cuff inflation from 0 to 40 ml in 10‐ml steps. In addition, intracuff pressure, fibreoptic position of the airway and drain tube, device insertion success, ventilation success, blood staining and airway morbidity were determined. Mean (SD) oropharyngeal leak pressures for clinically acceptable cuff volumes of 20–40 ml were 31 (7) cmH₂O for the GuardianCPV and 27 (7) cmH₂O for the LMA Supreme (p < 0.0001); mean (SD) intracuff pressures were 68 (33) cmH₂O and 88 (43) cmH₂O (p < 0.0001), respectively. We found no differences in device insertion success, ventilation success, fibreoptic position of the airway and drain tube, blood staining or airway morbidity. We conclude that the oropharyngeal leak pressure is better for the GuardianCPV than for the LMA Supreme in anaesthetised patients.     

A randomised trial comparing real‐time double‐lumen endobronchial tube placement with the Disposcope® with conventional blind placement

Double‐lumen endobronchial tube placement is challenging. This study compared double‐lumen tube placement with the Disposcope ^® , a wireless videostylet allowing real‐time visualisation, with conventional blind placement. Patients undergoing elective thoracic surgery with normal airways requiring one‐lung ventilation were randomly allocated into two groups (27 patients in each group). The Disposcope was used to assist left‐sided double‐lumen tube placement in one group, and conventional blind placement was performed in the control group. Placement in both groups was checked with fibreoptic bronchoscopy. The Disposcope‐assisted group had a shorter total mean (SD) placement time (18.6 (2.5) s vs. 21.4 (2.9) s, p < 0.001), laryngoscopy to end of auscultation time (83.4 (3.0) s vs. 93.9 (5.7) s, p < 0.001) and total operation time (130.7 (6.1) s vs. 154.5 (6.3) s, p < 0.001). In the Disposcope‐assisted group, the double‐lumen tube was inserted in the correct side in all patients (100.0%), whereas in the conventional group, the double‐lumen tube was placed in the correct side in 25 (92.6%) patients and in the wrong side in 2 (7.4%) patients; the difference was not significant (p = 0.150). In the Disposcope‐assisted group, the double‐lumen tube was inserted to the optimal depth in 24 (88.9%) patients, whereas in the conventional group it was inserted to the optimal depth in one (4.0%) patient. The Disposcope increased the success rate of double‐lumen tube placement, and shortened the total operation time when compared with standard placement with confirmation using fibreoptic bronchoscopy, and may replace the conventional method.