Flexible nasal bronchoscopy vs. Airtraq® videolaryngoscopy for awake tracheal intubation: a randomised controlled non-inferiority study

Videolaryngoscopy is a suitable alternative to flexible bronchoscopy to facilitate awake tracheal intubation. The relative effectiveness of these techniques in clinical practice is unknown. We compared flexible nasal bronchoscopy with Airtraq^® videolaryngoscopy in patients with an anticipated difficult airway scheduled for awake tracheal intubation. Patients were allocated randomly to flexible nasal bronchoscopy or videolaryngoscopy. All procedures were performed with upper airway regional anaesthesia blockade and a target-controlled intravenous infusion of remifentanil. The success rate with the allocated technique was the primary outcome. A non-inferiority analysis with a predefined limit of 8% was planned. Seventy-eight patients were recruited, allocated randomly and analysed. The rate of successful intubation was 97% and 82% in the flexible bronchoscopy and videolaryngoscopy groups, respectively, p = 0.032. The median (IQR [range]) time to tracheal intubation was shorter with the Airtraq, 163 (105–332 [40–1004]) vs. 217 (180–364 [120–780]) s, p = 0.030. There were no significant differences for complications found between the groups. The median visual analogue scale for ease of intubation was 8 (7–9 [0–10]) for Airtraq vs. 8 (7–9 [0–10]) for flexible bronchoscopy, p = 0.710. The median visual analogue scale for patient comfort for Airtraq was 8 (6–9 [2–10]) vs. 8 (7–9 [3–10]) for flexible bronchoscopy, p = 0.370. The Airtraq videolaryngoscope is not non-inferior to flexible bronchoscopy for awake tracheal intubation in a clinical setting when awake tracheal intubation is indicted. It may be a suitable alternative when judged on a case-by-case basis.     

Epistaxis during nasotracheal intubation: a randomized trial of the Parker Flex-Tip™ nasal endotracheal tube with a posterior facing bevel <Emphasis Type="Italic">versus</Emphasis> a standard nasal RAE endotracheal tube

Purpose

Nasotracheal intubation is a widely performed technique to facilitate anesthesia induction during oral, dental, and maxillofacial surgeries. The technique poses several risks not encountered with oropharyngeal intubation, most commonly epistaxis due to nasal mucosal abrasion. The purpose of this study was to test whether the use of the Parker Flex-Tip? (PFT) nasal endotracheal tube (ETT) with a posterior facing bevel reduces epistaxis when compared with the standard nasal RAE ETT with a leftward facing bevel.

Methods

Sixty American Society of Anesthesiologists physical status I and II patients undergoing oral or maxillofacial surgery with nasotracheal intubation were recruited. Patients were randomized to either a standard nasal RAE ETT or a PFT nasal ETT. The ETT was thermosoftened and lubricated for both study groups prior to insertion, and the size of the tube was chosen at the discretion of the attending anesthesiologist. The primary outcome was the incidence of epistaxis, with a secondary outcome of epistaxis severity (scored as none, mild, moderate, or severe). An investigator measured both outcomes five minutes after intubation was completed.

Results

Mild or moderate epistaxis was experienced by 22 of 30 (73%) patients in the PFT group compared with 21 of 30 (70%) patients in the standard nasal RAE ETT group (absolute risk reduction, 3%; 95% confidence interval, ?19 to 25; P = 0.78). There were no occurrences of severe epistaxis in either group.

Conclusion

There was no difference in the incidence or severity of epistaxis following nasal intubation using the Parker Flex-Tip nasal ETT when compared with a standard nasal RAE ETT. This trial was registered at ClinicalTrials.gov, identifier: NCT02315677.

     

The Flex-Tip™ tracheal tube does not reduce the incidence of postoperative sore throat: a randomized controlled trial

Purpose

Sore throat after tracheal intubation is common with an incidence of 30-70%. The Parker Flex-Tip? endotracheal tube (ETT) is designed to reduce trauma during ETT placement. This randomized single-blinded trial was designed to assess whether using the Flex-Tip ETT would reduce the incidence of postoperative sore throat and/or vocal change.

Methods

A Flex-Tip or a Mallinckrodt Hi–Lo® cuffed ETT was used by random allocation in 200 patients with normal-appearing airways requiring elective orotracheal intubation. On the second postoperative day, a blinded assessor recorded the incidence and severity of postoperative sore throat and voice alteration. The primary outcome was the incidence of moderate or severe sore throat. Secondary outcomes included vocal change, time to intubation, number of attempts/failures, incidence of oropharyngeal bleeding, and subjective ease of intubation.

Results

Demographic data were similar between the two groups. Moderate or severe sore throat was observed in 12% of patients with the Flex-Tip ETT and 6% of patients with the Mallinckrodt Hi–Lo ETT (odds ratio [OR] 2.1; 95% confidence intervals [CI] 0.70 to 7.1; P = 0.14). The incidence of moderate or severe vocal change was 6% and 3%, respectively (OR 2.0; 95% CI 0.42 to 12.9; P = 0.50). Time to intubation, number of intubation attempts, incidence of oropharyngeal bleeding, and ease of intubation did not differ significantly between groups.

Conclusion

In this study involving experienced clinicians, no significant difference was observed in the incidence of postoperative sore throat or vocal change between the Flex-Tip ETT and the standard Mallinckrodt Hi-Lo cuffed ETT. This trial was registered at www.clinicaltrials.gov, NCT01095861.     

A randomised, controlled trial comparing the Airtraq™ optical laryngoscope with conventional laryngoscopy in infants and children

The Airtraq^? optical laryngoscope became available in paediatric sizes in the UK in May 2008. We conducted a randomised, controlled trial comparing the Airtraq with conventional laryngoscopy during routine anaesthesia in children. We hypothesised that the Airtraq laryngoscope would perform as well as conventional laryngoscopy. Sixty patients (20 infants and 40 children) were recruited. The mean (SD) intubation time using the Airtraq was longer than conventional laryngoscopy overall (47.3 (32.6) vs 26.3 (11.5) s; p = 0.002), though the difference was only significant for children (p = 0.003) and not for infants (p = 0.29). The Airtraq provided a better view of the larynx compared with conventional laryngoscopy (in infants (percentage of glottic opening scores 100 (95–100 [90–100]) vs 77 (50–90 [40–100]), respectively; p = 0.001; visual analogue scores for field of view 9.2 (9.2–9.5 [8.2–10.0]) vs 6.8 (5.1–8.0 [4.7–10.0]), respectively; p = 0.001). In children, the Airtraq provided a similar view of the larynx (percentage of glottic opening scores 100 (100–100 [40–100]) vs 100 (90–100 [50–100]), respectively; visual analogue scores for field of view 9.2 (8.6–10.0 [7.0–10.0]) vs 9.2 (8.6–10.0 [5.6–10.0]), respectively; both p > 0.05), compared with conventional laryngoscopy.     

A randomised trial comparing the laryngeal mask airway Supreme™ with the laryngeal mask airway Unique™ in children

We conducted a randomised controlled trial comparing the laryngeal mask airway Supreme^? with the laryngeal mask airway Unique^? in children. Fifty children presenting for elective surgery were randomly assigned to receive either the laryngeal mask airway Supreme or laryngeal mask airway Unique. The outcomes measured were airway leak pressure, ease and time for insertion, insertion success rate, fibreoptic examination, incidence of gastric insufflation, ease of gastric tube placement through the laryngeal mask airway Supreme, quality of airway during anaesthetic maintenance and complications. Median (IQR [range]) time to successful device placement was shorter with the laryngeal mask airway Unique, 14.5 [13.5–16.3 (10.0–23.6)] s than with the laryngeal mask airway Supreme, 17.4 [14.8–19.8 (11.5–29.2)] s; p = 0.007. Median (IQR [range]) airway leak pressures for the laryngeal mask airway Supreme and laryngeal mask airway Unique were 20 [16–21 (12–22)] cmH₂O and 15 [14–18 (10–24)] cmH₂O, respectively (p = 0.001). The incidence of gastric insufflation was lower with the laryngeal mask airway Supreme (zero vs six patients), p = 0.01. In conclusion, the laryngeal mask airway Supreme performed as well as the laryngeal mask airway Unique and is a useful alternative for airway maintenance, particularly in children who require evacuation of gastric contents during anaesthesia.     

A prospective randomised trial comparing the modified HM3 with the MODULITH® SLX-F2 lithotripter

Background

The relative efficacy of first- versus last-generation lithotripters is unknown.

Objectives

To compare the clinical effectiveness and complications of the modified Dornier HM3 lithotripter (Dornier MedTech, Wessling, Germany) to the MODULITH^® SLX-F2 lithotripter (Storz Medical AG, Tägerwilen, Switzerland) for extracorporeal shock wave lithotripsy (ESWL).

Design, setting and participants

We conducted a prospective, randomised, single-institution trial that included elective and emergency patients.

Interventions

Shock wave treatments were performed under anaesthesia.

Measurements

Stone disintegration, residual fragments, collecting system dilatation, colic pain, and possible kidney haematoma were evaluated 1 d and 3 mo after ESWL. Complications, ESWL retreatments, and adjuvant procedures were documented.

Results and limitations

Patients treated with the HM3 lithotripter (n = 405) required fewer shock waves and shorter fluoroscopy times than patients treated with the MODULITH^® SLX-F2 lithotripter (n = 415). For solitary kidney stones, the HM3 lithotripter produced a slightly higher stone-free rate (p = 0.06) on day 1; stone-free rates were not significantly different at 3 mo (HM3: 74% vs MODULITH^® SLX-F2: 67%; p = 0.36). For solitary ureteral stones, the stone-free rate was higher at 3 mo with the HM3 lithotripter (HM3: 90% vs MODULITH^® SLX-F2: 81%; p = 0.05). For solitary lower calyx stones, stone-free rates were equal at 3 mo (63%). In patients with multiple stones, the HM3 lithotripter's stone-free rate was higher at 3 mo (HM3: 64% vs MODULITH^® SLX-F2: 44%; p = 0.003). Overall, HM3 lithotripter led to fewer secondary treatments (HM3: 11% vs MODULITH^® SLX-F2: 19%; p = 0.001) and fewer kidney haematomas (HM3: 1% vs. MODULITH^® SLX-F2: 3%; p = 0.02).

Conclusions

The modified HM3 lithotripter required fewer shock waves and shorter fluoroscopy times, showed higher stone-free rates for solitary ureteral stones and multiple stones, and led to fewer kidney haematomas and fewer secondary treatments than the MODULITH^® SLX-F2 lithotripter. In patients with a solitary kidney and solitary lower calyx stones, results were comparable for both lithotripters.     

A randomised controlled trial comparing two insertion techniques for the Laryngeal Mask Airway Flexible™ in patients undergoing dental surgery

The Laryngeal Mask Airway Flexible^TM (LMA Flexible) has been widely utilised for dental, ophthalmology and otorhinolaryngology‐related procedures. Our study evaluates two different techniques of inserting the LMA Flexible for patients undergoing day‐case dental surgery. One hundred and eight patients were randomly assigned into two groups based on the LMA Flexible insertion technique – either laryngoscopy‐guided (n = 54) or digital manipulation (standard technique; n = 54). Patient and airway characteristics were recorded before induction of anaesthesia. The primary outcome was success rate at first insertion. Other outcomes assessed included fibreoptic assessment of laryngeal mask airway placement, haemodynamic changes, need for airway adjustment during surgery and sore throat. The success rate of insertion on the first attempt was higher for the laryngoscopy‐assisted technique compared with the standard technique (96.3% vs 81.5%, respectively, p < 0.05). Fibreoptic assessment showed that the former group had better placement of the laryngeal mask airway than the latter (59.3% vs 37% p < 0.05). There were no significant differences between the two groups for haemodynamic changes. Sore throat was more common in the group with the standard technique (35.2% vs 16.7%, p < 0.05). Our study suggests the use of the laryngoscope to guide insertion of the LMA Flexible for dental surgery is a better option compared with the standard technique of digital manipulation.