Awake intubation of the adult trachea using the Bullard laryngo-scope

Awake intubation using the Bullard laryngoscope can be comfortably and easily performed in the adult. Five cases are presented in which tracheal intubation was performed under topical anaesthesia with light intravenous sedation. In each case, topical anaesthesia was performed by insertion of a Guedel oral airway, with lidocaine ointment applied to the inferior and posterior surfaces. In one case, Bullard intubation was successful where direct laryngoscopy and multiple attempts at bronchoscopic intubation by three different operators had failed. We conclude that the Bullard laryngoscope can be easily used in awake patients and may be a useful alternative where other methods for awake intubation have failed.     

A novel modified method of using Trachway intubating stylet for awake tracheal intubation in patients with anticipated difficult airway

The Trachway intubating stylet is designed to facilitate tracheal intubation in anesthetized patients with a normal or difficult airway anatomy. The shortcoming of this device is the lack of a working channel to provide topicalization of the airway. We describe a novel modified method of using Trachway intubating stylet to provide airway topicalization and perform awake orotracheal intubation in two cases with an anticipated difficult airway. The first case was a superobese patient with a cervical spine disorder, whereas the second case was a patient with an enlarged thyroid gland. Transtracheal lidocaine injection was technically difficult in these patients because of neck obesity and thyroid enlargement, respectively. We believe that this modified method can be used to provide effective airway topicalization when Trachway intubating stylet is used for awake orotracheal intubation.     

A comparison of the GlideScope with the Macintosh laryngoscope for tracheal intubation in patients with simulated difficult airway

We compared the use of the GlideScope and the conventional Macintosh laryngoscope in a simulated difficult airway. The primary hypothesis was that time to intubation would be shorter using the GlideScope than using the Macintosh laryngoscope. After obtaining approval from the ethics committee and written informed consent, we recruited 60 ASA 1 and 2 patients to our randomized controlled trial. Group G (n = 30) had tracheal intubation performed using the GlideScope and Group M (n = 30) were intubated using a Macintosh laryngoscope. We simulated a difficult airway in each patient by having an experienced assistant provide in-line manual stabilization of the head and neck. We recorded the best laryngeal view; difficulty of the tracheal intubation; time taken for successful tracheal intubation; manoeuvre needed to aid tracheal intubation and complications associated with the tracheal intubation. The median Cormack and Lehane grade was significantly better in Group G than Group M. Group G had a significantly shorter intubation time than group M (mean 41.8s +/- SD 20.2 vs mean 56.2s +/- 26.6, P < 0.05). The GlideScope improved the laryngeal view and decreased time for tracheal intubation time when compared with the Macintosh laryngoscope in patients with simulated difficult airway. The GlideScope may be a good alternative for managing the difficult airway but clinical trials evaluating its use on patients with an actual difficult airway are needed.     

Usability of AirWay Scope for awake tracheal intubation in a burn patient with difficult airway

The AirWay Scope (AWS; PENTAX Corporation, Tokyo, Japan) is a newly developed rigid video laryngoscope with a built-in LCD monitor that provides accurate verification of tube passage through the vocal cords during tracheal intubation procedures. The blade is shaped to fit the oropharyngeal anatomy, which enables operators to achieve an optimal view for tracheal intubation without requiring alignment of the oral, pharyngeal, and laryngeal axes. We used an AWS for awake intubation in a 34-year-old male burn patient with a difficult airway under conscious sedation obtained with infusion of dexmedetomidine (DEX). Following topical anesthesia of the upper airway and preoxygenation, sedation was induced with 6 microg kg(-1) hr(-1) of DEX for 13 minutes and maintained at 0.5 microg kg(-1) hr(-1). Thereafter, insertion of the AWS gave a Cormack grade 1 glottic view, and endotracheal anesthesia was provided by use of a modified spray tube through the AWS blade without patient anxiety or discomfort. The trachea was intubated using the AWS without respiratory depression or other complications while the patient was sedated (Ramsay sedation scale class 4). We consider the AWS to be useful for awake tracheal intubation in patients with a difficult airway.     

Performance of the Airtraq™ laryngoscope after failed conventional tracheal intubation: a case series

Background: The Airtraq^™, a new disposable indirect laryngoscope, was evaluated in patients with difficult intubation.
Methods: The Airtraq^™ was used in 47 patients with predicted or unpredicted difficult intubation after failed orotracheal intubation performed by two senior anaesthesiologists with the Macintosh laryngoscope.
Results: Tracheal intubation with Airtraq^™ was successful in 36 patients (80%). The Cormack and Lehane score was IIb–III in 35 patients, and IV in 12 patients, with the Macintosh laryngoscope, while Cormack and Lehane score was I–IIa in 40 patients, IIb–III in three and IV in four with Airtraq^™. A gum elastic bougie was used to facilitate tracheal access in one-third (11/36) of the cases. Orotracheal intubation was not possible with Airtraq^™ in nine cases, five of whom had a pharyngeal, laryngeal or basal lingual tumour.
Conclusion: In patients with difficult airway, following failed conventional orotracheal intubation, Airtraq^™ allows securing the airway in 80% of cases mainly by improving glottis view. However, the Airtraq^™ does not guarantee successful intubation in all instances, especially in case of laryngeal and/or pharyngeal obstruction.     

Use of a gum elastic bougie for tracheal intubation with Pentax-AWS airway scope

Pentax-AWS laryngoscope (Pentax, Tokyo, Japan) consists of a disposable anatomically shaped blade, a 12-cm cable with a charge-coupled device (CCD) camera and a 2.4-inch liquid crystal device (LCD) color monitor display. A tracheal tube can be attached to the right side of the blade. The device may be useful in patients with difficult airways. One limitation of the device is that intubation may be difficult if it is difficult to position the glottis to the target symbol on the monitor display. We experienced such a difficulty in four patients, and the use of a gum elastic bougie enabled intubation. In a 57-year-old woman with a difficult airway, tracheal intubation using either a Macintosh laryngoscope or a fiberscope had failed. By inserting the AWS laryngoscope, the glottis was easily seen on the monitor display. Nevertheless, it was difficult to position the glottis to the target symbol, and advancing a tracheal tube collided with the tissue around the glottis. A bougie was passed through the tracheal tube, and it became possible to insert the bougie into the trachea by adjusting the angle of its tip. The tracheal tube was then easily passed over the bougie into the trachea. We successfully used the same technique in other three patients. We believe that the gum elastic bougie can be useful for tracheal intubation using the Pentax-AWS laryngoscope.     

Le glottiscope AWS-Pentax™, alternative à la fibroscopie dans deux cas d’intubation difficile prévue du brûlé grave

Intubating patients with facial burn is difficult to most anesthesiologists. Awake flexible fiberoptic intubation is the gold standard for management of anticipated difficult tracheal intubation. However, serious facial burn and dysmorphic syndrome can make fiberoptic intubation more difficult or impossible. We report the use of awake oral intubation using the Pentax-Airway Scope (AWS) in two major burn patients with facial injury, in whom awake fiberoptic intubation was impossible. As shown in morbidly obese patient and in patients with unstable necks, AWS could be useful to facilitate tracheal intubation in awake, facial burn patients presenting with a potentially difficult airway. Awake AWS intubation seems as a potential alternative to awake fiberoptic intubation.     

Double lumen tube insertion in awake patients through the AirTraq laryngoscope in 2 cases of expected difficult airway

The likelihood of difficult airway in thoracic surgery increases in the presence of associated cancer of the pharynx or larynx. The difficulty is greater when a double lumen tube must be inserted in these conditions, and various newly developed optical devices offer solutions for managing such cases. We report on 2 patients with expected difficult airway who were scheduled for lung resection. In both cases, intubation was accomplished through the AirTraq laryngoscope while the patient remained awake. Awake patient tolerance is facilitated by this laryngoscope, because the tube can be inserted without changing the position of the tongue or placing pressure on the vallecula.     

Tracheal intubation of morbidly obese patients: a randomized trial comparing performance of Macintosh and Airtraq laryngoscopes

BACKGROUND: The Airtraq laryngoscope is designed to allow visualization of the glottis without alignment of the oral, pharyngeal, and laryngeal axes. We hypothesized that this new airway device would facilitate tracheal intubation of morbidly obese patients. We compared tracheal intubation performance of standard Macintosh laryngoscope with the Airtraq laryngoscope in morbidly obese patients. METHODS: One hundred and six consecutive ASA I-III morbidly obese patients undergoing surgery were randomized to intubation with the Macintosh laryngoscope or the Airtraq laryngoscope. Induction of anaesthesia was standardized. If tracheal intubation failed within 120 s with the Macintosh or Airtraq , laryngoscopes were switched. Success rate, SpO2, duration of tracheal intubation, and quality of airway management were evaluated and compared between the groups. RESULTS: Preoperative characteristics of the patients were similar in both groups. In the Airtraq group, tracheal intubation was successfully carried out in all patients within 120 s. In the Macintosh laryngoscope group, six patients required intubation with the Airtraq laryngoscope. The mean (SD) time taken for tracheal intubation was 24 (16) and 56 (23) s, respectively, with the Airtraq and Macintosh laryngoscopes, (P<0.001). SpO2 was better maintained in the Airtraq group than in the Macintosh laryngoscope group with one and nine patients, respectively, demonstrating drops of SpO2 to 92% or less (P<0.05). CONCLUSIONS: In this study, the Airtraq laryngoscope shortened the duration of tracheal intubation and prevented reductions in arterial oxygen saturation in morbidly obese patients.     

A comparison of McGrath and Macintosh laryngoscopes in novice users: a manikin study

Direct laryngoscopy using the Macintosh laryngoscope is a difficult skill to acquire. Videolaryngoscopy is a widely accepted airway management technique that may be easier for novices to learn. We compared the McGrath^® videolaryngoscope and Macintosh laryngoscope by studying the performance of 25 medical students with no previous experience of performing tracheal intubation using an easy intubation scenario in a manikin. The order of device use was randomised for each student. After brief instruction each participant performed eight tracheal intubations with one device and then eight tracheal intubations with the other laryngoscope. Novices achieved a higher overall rate of successful tracheal intubation, avoided oesophageal intubation and produced less dental trauma when using the McGrath. The view at laryngoscopy was significantly better with the McGrath. Intubation times were similar for both laryngoscopes and became shorter with practice. There was no difference in participants' rating of overall ease of use for each laryngoscope.     

Awake tracheal intubation through the intubating laryngeal mask airway in a patient with halo traction

PURPOSE: To report a case of awake tracheal intubation through the intubating laryngeal mask airway (ILMA) in a patient with halo traction. Clinical features: A 16-yr-old, 40 kg, boy with atlanto-occipital instability and halo traction was scheduled for surgery under general anesthesia. The head of the patient was fixed in a position of flexion and extension was impossible. Cranial magnetic resonance imaging revealed that pharyngeal and laryngeal axes were aligned, but that the oral axis was in an extreme divergent plane. The tongue and oropharynx were anesthetized with 10% lidocaine spray and bilateral superior laryngeal nerve blockade was performed. Under sedation, awake orotracheal intubation via ILMA was successful. Fibreoptic bronchoscopy has been recommended for awake tracheal intubation in such patients. Other techniques, such as use of the Bullard laryngoscope have been described also but awake tracheal intubation through the ILMA in patients with a halo device in situ has seldom been reported in the medical literature. CONCLUSION: Airway management of patients with cervical spine instability includes adequate preoperative evaluation of the airway and choosing the appropriate intubation technique. We suggest that the ILMA may be an adequate alternative for awake tracheal intubation in patients with an unstable cervical spine and cervical immobilization with a halo device.     

A randomised comparison of InnoScope and Macintosh laryngoscope in simulated difficult tracheal intubation in manikins

We conducted a crossover randomised study to evaluate the performance of a novel optical stylet, the InnoScope, for tracheal intubation in simulated normal and difficult airways. Twenty‐five anaesthetists attempted tracheal intubation on a SimMan 3G simulator using the InnoScope first followed by the Macintosh laryngoscope or vice versa. Three airway scenarios were tested: (1) normal airway; (2) difficult airway with swollen pharynx; and (3) limited neck movement. In each scenario, the laryngeal view, duration of and success rate for tracheal intubation were recorded. Compared with the Macintosh laryngoscope, the use of InnoScope increased the percentage of glottic opening seen by 17% in normal airway, 23% in the difficult airway and 32% with limited neck movement, p < 0.01. Despite this better laryngeal view, successful tracheal intubation achieved with the InnoScope (88.0%) was lower than that for the Macintosh laryngoscope (98.7%), p = 0.008. Using the InnoScope, tracheal intubation during the first attempt was only successful in 48% of cases with difficult airway. In this scenario, the median (interquartile range [range]) duration of tracheal intubation was significantly longer with the InnoScope (53 (20–100 [15–120]) s) compared with the Macintosh laryngoscope (27 (20–62 [15–120]) s), p = 0.01. We conclude that an improved laryngeal view with the use of the InnoScope did not translate into better conditions for tracheal intubation.     

The Pentax-AWS((R)) rigid indirect video laryngoscope: clinical assessment of performance in 320 cases

The Pentax-AWS airway scope system is a rigid indirect video laryngoscope with integrated tube guidance. Laryngoscopy and intubation are visualised using a built in LCD monitor which displays the view obtained by a CCD camera mounted in the tip of the laryngoscope. We describe its clinical performance in 320 patients. The Pentax-AWS significantly improved the laryngeal view compared to the Macintosh laryngoscope. Forty-six patients (14%) who were classified as Cormack Lehane glottic view grade 3 or 4 using the Macintosh laryngoscope were classified as grade 1 (45 cases) or 2a (1 case) using the Pentax-AWS airway scope. Laryngeal views measured by percentage of glottic opening score were improved significantly using the Pentax-AWS. Intubation using the Pentax-AWS was successful in all cases, 96% at the first and 4% at the second attempt. The mean (SD) time required to place the tracheal tube was 20 (10) s. The Cormack Lehane grade obtained with the Macintosh blade did not affect the total time to correctly position the tube using the Pentax-AWS. Intubation difficulty scale (score = 0 in 305 patients, score = 1 in 14 and score = 2 in one patient) indicates that tracheal intubation was performed easily in most cases. The Pentax-AWS not only improves the laryngeal view, but its tube guide also facilitates rapid, easy and reliable tracheal intubation under vision. It can be useful in routine anesthesia care and may be advantageous in the situation of unanticipated difficult intubation.     

A comparison of tracheal intubation using the Airtraq or the Macintosh laryngoscope in routine airway management: A randomised, controlled clinical trial

The Airtraq laryngoscope is a novel single use tracheal intubation device. We compared the Airtraq with the Macintosh laryngoscope in patients deemed at low risk for difficult intubation in a randomised, controlled clinical trial. Sixty consenting patients presenting for surgery requiring tracheal intubation were randomly allocated to undergo intubation using a Macintosh (n = 30) or Airtraq (n = 30) laryngoscope. All patients were intubated by one of four anaesthetists experienced in the use of both laryngoscopes. No significant differences in demographic or airway variables were observed between the groups. All but one patient, in the Macintosh group, was successfully intubated on the first attempt. There was no difference between groups in the duration of intubation attempts. In comparison to the Macintosh laryngoscope, the Airtraq resulted in modest improvements in the intubation difficulty score, and in ease of use. Tracheal intubation with the Airtraq resulted in less alterations in heart rate. These findings demonstrate the utility of the Airtraq laryngoscope for tracheal intubation in low risk patients.     

Evaluation of the Airtraq and Macintosh laryngoscopes in patients at increased risk for difficult tracheal intubation

The Airtraq, a novel single use indirect laryngoscope, has demonstrated promise in the normal and simulated difficult airway. We compared the ease of intubation using the Airtraq with the Macintosh laryngoscope, in patients at increased risk for difficult tracheal intubation, in a randomised, controlled clinical trial. Forty consenting patients presenting for surgery requiring tracheal intubation, who were deemed to possess at least three characteristics indicating an increased risk for difficulty in tracheal intubation, were randomly assigned to undergo tracheal intubation using a Macintosh (n = 20) or Airtraq (n = 20) laryngoscope. All patients were intubated by one of three anaesthetists experienced in the use of both laryngoscopes. Four patients were not successfully intubated with the Macintosh laryngoscope, but were intubated successfully with the Airtraq. The Airtraq reduced the duration of intubation attempts (mean (SD); 13.4 (6.3) vs 47.7 (8.5) s), the need for additional manoeuvres, and the intubation difficulty score (0.4 (0.8) vs 7.7 (3.0)). Tracheal intubation with the Airtraq also reduced the degree of haemodynamic stimulation and minor trauma compared to the Macintosh laryngoscope.     

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.     

Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults

Awake tracheal intubation has a high success rate and a favourable safety profile but is underused in cases of anticipated difficult airway management. These guidelines are a comprehensive document to support decision making, preparation and practical performance of awake tracheal intubation. We performed a systematic review of the literature seeking all of the available evidence for each element of awake tracheal intubation in order to make recommendations. In the absence of high-quality evidence, expert consensus and a Delphi study were used to formulate recommendations. We highlight key areas of awake tracheal intubation in which specific recommendations were made, which included: indications; procedural setup; checklists; oxygenation; airway topicalisation; sedation; verification of tracheal tube position; complications; management of unsuccessful awake tracheal intubation; post-tracheal intubation management; consent; and training. We recognise that there are a range of techniques and regimens that may be effective and one such example technique is included. Breaking down the key practical elements of awake tracheal intubation into sedation, topicalisation, oxygenation and performance might help practitioners to plan, perform and address complications. These guidelines aim to support clinical practice and help lower the threshold for performing awake tracheal intubation when indicated.     

Remifentanil for conscious sedation and analgesia during awake fiberoptic tracheal intubation: a case report with pharmacokinetic simulations.

We report a case of awake, fiberoptic tracheal intubation of a difficult airway (Ludwig's angina) using remifentanil as part of the sedation-analgesia regimen. Remifentanil's rapid onset-rapid offset pharmacokinetic profile enabled precise control of the level of opioid effect. In combination with other drugs, remifentanil may offer some clinical advantages compared to the other fentanyl congeners in providing the opioid component of conscious sedation-analgesia for awake tracheal intubation in patients with difficult airways.     

A ventilation-exchange bougie for fibreoptic intubations with the laryngeal mask airway

The ventilation-exchange bougie is a new airway device which can be mounted on a fibreoptic laryngoscope for passage through the larynx into the trachea via a laryngeal mask airway. Subsequent removal of the fibreoptic laryngoscope and laryngeal mask airway allows a tracheal tube to be railroaded into position over the ventilation-exchange bougie. This study described the use of this technique for elective tracheal intubation in two groups of 12 subjects in whom difficulty with intubation was not expected. All the subjects were successfully intubated by one of two anaesthetists, one experienced and the other inexperienced with fibreoptic intubation techniques. Neither had had prior experience with the ventilation-exchange bougie. Because ventilation was maintained throughout the procedure, intubation did not need to be hurried. Cusum analysis confirmed the impression of a learning curve and the technique could be considered learnt after four and six intubations for the experienced and inexperienced fibreoptic larvngoscopists respectively. No difficulty was found either in intubating the larynx with the fibreoptic laryngoscope and ventilation-exchange bougie or when railroading the tracheal tube over the ventilation-exchange bougie. It is suggested that this new device could have an important role in teaching fibreoptic techniques, management of the difficult airway and failed intubations.     

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.