Evaluación del videolaringoscopio Airtraq como dispositivo de rescate tras laringoscopia directa difícil

Background and objectives

Unexpected difficult tracheal intubation and failure to intubate are among the leading causes of anesthesia-related morbidity and mortality. This study was undertaken to evaluate the effectiveness of the Airtraq video laryngoscope for tracheal intubation after difficult direct laryngoscopy.

Evaluation of the Bullard, GlideScope, Viewmax, and Macintosh laryngoscopes using a cadaver model to simulate the difficult airway

Study Objective

To assess the performance and cervical (C)-spine movement associated with laryngoscopy using the Bullard laryngoscope (BL), GlideScope videolaryngoscope (GVL), Viewmax, and Macintosh laryngoscopes during conditions of a) unrestricted and b) restricted C-spine and temporomandibular joint (TMJ) mobility.

Design

Prospective, controlled, randomized, crossover study.

Setting

University teaching hospital.

Subjects

21 cadavers with intact C-spine anatomy.

Interventions

Each cadaver underwent to total of 8 intubation attempts to complete the intubation protocol using all four devices under unrestricted and restricted C-spine and TMJ mobility.

Measurements

Laryngoscopic view was graded using the modified Cormack-Lehane system. Time to best laryngoscopic view and total time to intubation were recorded. C-spine movement was measured between McGregor's line and each vertebra from radiographs taken at baseline and at best laryngoscopic view.

Main Results

During both intubating conditions, the BL achieved the highest number of modified Cormack-Lehane grade 1 and 2A laryngoscopic views as compared to the other three devices (P < 0.05) and had fewer intubation failures than the Viewmax or Macintosh laryngoscopes (P < 0.05). The GVL had superior laryngoscopic performance as compared to the Viewmax and Macintosh laryngoscopes (P < 0.05) and had fewer intubation failures than those two devices (P < 0.05). All devices except the Macintosh laryngoscope in restricted mobility achieved median times to intubation in less than 30 seconds. For both conditions, BL showed the least total absolute movement between Occiput/C1 and C3/C4 of all the devices (all P < 0.05). Most of the difference was seen at C1/C2.

Conclusions

In cadavers with unrestricted and restricted C-spine mobility, the BL provided superior laryngoscopic views, comparable intubating times, and less C-spine movement than the GVL, Viewmax, or Macintosh laryngoscopes.     

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

Introduction

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

Study design

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

Patients and methods

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

Results

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

Conclusion

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

The learning curve for laryngoscopy: Airtraq versus Macintosh laryngoscopes

Purpose

Airtraq use by inexperienced personnel has been evaluated in simulator studies, but little is known about the learning process in real patients. This prospective study was designed to compare learning curves for laryngoscopy with the Airtraq or Macintosh laryngoscopes in patients under general anesthesia.

Methods

Ten medical students with no prior experience in airway management were recruited on a voluntary basis and underwent training in Macintosh and Airtraq laryngoscopy. Patients with no difficult intubation criteria were enrolled after consent. Each student performed laryngoscopy with either device on ten consecutive patients. Success was defined as Cormack–Lehane grading ≤2. We also recorded subjective difficulty scores on an 11-point numerical rating scale. Learning curves were drawn using cumulative success rates and 95% confidence intervals calculated with bootstrap procedures.

Results

The mean (95% CI) success rates for the procedures were 86.0% (76.7–93.3%) for the Airtraq and 64.0% (52.0–75.0%) for the Macintosh laryngoscope. Differences in success rate were significant from the fourth attempt and were 22.0% (8.2–36.5%) after the tenth. Seven students achieved success rates ≥90% using the Airtraq, versus one using the Macintosh (P?=?0.022). Median (25th–75th percentile) difficulty scores were 2 (1–4) and 4 (2–6), respectively (P?Conclusion Students achieved higher success rates using the Airtraq laryngoscope during early training on live patients. The Airtraq may be a useful choice for teaching advanced airway management, especially to professionals who will not perform laryngoscopy on a regular basis.     

Nasotracheal intubation using the Airtraq versus Macintosh laryngoscope: a manikin study

The Airtraq laryngoscope is a new intubation device that provides a non-line-of-sight view of the glottis. We evaluated this device by comparing the ease of nasotracheal intubation on a manikin with the use of Airtraq versus the Macintosh laryngoscope with and without Magill forceps. Nasotracheal intubation on a manikin was performed by 20 anesthesiologists and 20 residents with the Airtraq or Macintosh laryngoscope. The mean (+/- SD) time required for nasotracheal intubation by the residents was significantly shorter with the Airtraq laryngoscope than with the Macintosh laryngoscope (16 +/- 7 sec vs 22 +/- 10 sec; P < .001), but no difference in intubation time was observed between Airtraq (15 +/- 11 sec) and Macintosh (13 +/- 6 sec) laryngoscopy by the anesthesiologists. The Magill forceps was used more frequently to facilitate intubation with the Macintosh laryngoscope than with the Airtraq laryngoscope in both groups of operators 7(P < .001). The Airtraq laryngoscope scored better on the visual analog scale than did the Macintosh laryngoscope in both groups of operators (P < .05). The Airtraq laryngoscope offers potential advantages over standard direct laryngoscopy for nasotracheal intubation.     

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

Background

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

Distortion of anterior airway anatomy during laryngoscopy with the GlideScope videolaryngoscope

Purpose  

A non-line-of-sight view is expected to cause less movement of the anterior airway anatomy and cervical spine during laryngeal visualization. Reduced distortion of anterior airway anatomy during laryngoscopy with the GlideScope videolaryngoscope (GVL), compared with the Macintosh laryngoscope, could explain the relatively easier nasotracheal intubation with the GVL. The purpose of this radiographic study was to compare the degree of anterior airway distortion and cervical spine movement during laryngoscopy with the GVL and the conventional Macintosh laryngoscope.     

Extracorporeal membrane oxygenation as a bridge to definitive tracheal reconstruction in neonates

Purpose

Infants born with severe tracheal anomalies may not survive beyond the first few hours of life without aggressive cardiopulmonary support and/or emergent airway surgery. The purpose of this study was to review our experience with critically ill neonates supported on extracorporeal membrane oxygenation (ECMO) before tracheal reconstruction.

Methods

A retrospective review of a single institution ECMO registry was conducted. Outcomes of neonates requiring tracheal repair were examined.

Results

Three children with tracheal anomalies (complete tracheal rings [n = 2]; bronchogenic cyst [n = 1]) underwent definitive airway reconstruction. All were placed on ECMO (venovenous [n = 2]; venoarterial [n = 1]) within 24 hours after birth. Tracheoplasties (tracheal resection with end-to-end anastomosis [n = 1]; slide tracheoplasty [n = 1]; carinal resection and reconstruction [n = 1]) were performed at 3.7 ± 2.2 days of life. There were no hemorrhagic or thrombotic complications for an ECMO time of 117.3 ± 60.1 hours. The postoperative durations until extubation and hospital discharge were 12.0 ± 3.2 and 34.3 ± 11.6 days, respectively. All children remain alive and well without cardiopulmonary and neurologic sequelae at a mean follow-up of 4.5 years.

Conclusions

Excellent clinical outcomes can be achieved in neonates born with severe tracheal anomalies using ECMO as a bridge to definitive tracheal reconstruction.     

Significance of ductal plate malformation in the postoperative clinical course of biliary atresia

Purpose

Ductal plate malformation (DPM) is one of the etiologic theories for the development of biliary atresia (BA). In this study, we investigated the significance of DPM in the postoperative clinical course of BA, especially as a predictive factor of jaundice clearance.

Methods

Between 1988 and 2005, 31 patients with uncorrectable BA underwent hepatoportoenterostomy and steroid therapy. Immunohistochemistry was used to characterize biliary structures using cytokeratin 19. Specimens were defined as DPM-positive if a concentric cellular arrangement was detected. This retrospective study included comparisons of preoperative characteristics, the postoperative jaundice period, and cumulative steroid doses between patients with and without DPM.

Results

Of the 31 patients with uncorrectable BA, 25 (80.6%) became jaundice-free. Ductal plate malformation was detected in 11 (35.5%) of the 31. Between the 2 groups, there were no differences in preoperative characteristics or in the postoperative jaundice-free rate. Among those who became anicteric, the postoperative jaundice period was 145.3 ± 69.9 days in the DPM-positive group (n = 9) and 81.8 ± 44.7 days in the DPM-negative group (n = 16) (P < .05). The total administered steroids were 149.7 ± 78.2 and 95.0 ± 60.2 mg/kg, respectively (P = .09).

Conclusion

Ductal plate malformation may disturb bile flow and require more steroid to improve bile drainage. Therefore, the presence of DPM in the liver predicts poor bile flow after hepatoportoenterostomy in infants with BA.     

Laryngoscope plastic blades in scheduled general anesthesia patients: a comparative randomized study

Study Objective

To compare two brands of disposable plastic laryngoscope blades, Vital View plastic blades and Heine XP plastic blades, with the reusable Heine Classic+ Macintosh metal blades.

Design

Prospective randomized, controlled, single-blinded study.

Setting

Operating room of a university-affiliated hospital.

Patients

519 patients without criteria for predicted difficult intubation, undergoing scheduled surgery during general anesthesia.

Interventions

Patients were randomized to three groups according to laryngoscope blade brand.

Measurements

Difficult tracheal intubation was evaluated by the Intubation Difficulty Scale (IDS) (IDS > 5 = procedure involving moderate to major difficulty).

Main Results

The percentage of intubations with an IDS > 5 was 3.1% in Group M (metal blade group), 5.1% in Group V (Vital View plastic blade group), and 10.0% in Group H (Heine plastic blade group). A significant difference was noted between Groups M and H (P = 0.02) but not between Groups M and V.

Conclusions

Intubation may be more challenging when using Heine XP plastic blades but no significant difference exists between Vital-View plastic blades and Heine Classic+ metal blades.     

Extended left hepatectomy of the left and middle hepatic venous drainage areas along the anterior fissure

Background

Extended left hepatectomy including the middle hepatic vein (MHV) may potentially induce right paramedian sector congestion of the remnant liver.

Methods

To prevent venous congestion in the right paramedian sector, we performed extended left hepatectomy including the left hemiliver and anterior segment, which drain into the MHV and left hepatic vein (LHV), for 15 patients.

Results

In 11 of 15 patients (73%), temporary clamping of the common trunk of the MHV and LHV and the proper hepatic artery provided the anterior fissure. Regeneration rate of the middle segment was similar to that of the right lateral sector (10.8% vs 11.2%) on postoperative computed tomography (CT) after 3 months.

Conclusions

This procedure could represent a useful method for preventing postoperative venous congestion.     

Intravenous landiolol, a novel β(1)-adrenergic blocker, reduces the minimum alveolar concentration of sevoflurane in women

Study Objective

To investigate the effect of intravenous (IV) landiolol, a novel β₁-adrenergic blocker, on the minimum alveolar concentration (MAC) of sevoflurane in adult women.

Design

Prospective, randomized study.

Setting

University hospital.

Patients

42 ASA physical status 1 and 2 women, aged 24-57 years, who were scheduled to undergo elective abdominal surgery.

Interventions

Anesthesia was induced in all patients by vital capacity rapid inhalation induction of sevoflurane. In the landiolol group, administration of landiolol began when patients took a vital-capacity breath: 0.125 mg/kg/min for one minute and then 0.04 mg/kg/min. Normal saline was administered in the control group.

Measurements

MAC was determined by a technique adapted from the conventional up-down method.

Main Results

The MAC of sevoflurane was 2.2% ± 0.2% in the control group and 1.7% ± 0.2% in the landiolol group, a statistically significant difference (P = 0.0005).

Conclusions

IV landiolol reduces the MAC of sevoflurane in women by approximately 20%.     

Comparison of the Truview PCD™ and the GlideScope® video laryngoscopes with direct laryngoscopy in pediatric patients: a randomized trial

Introduction

The GlideScope^® video laryngoscope has a 60° angled blade and the blade of the Truview PCD? video laryngoscope has an optical lens that provides a 46° refraction of the viewing angle. Despite successful results using the GlideScope in adults, few studies have been published regarding its use in pediatric patients. We therefore tested our joint primary hypothesis that the GlideScope and the Truview PCD video laryngoscopes provide superior visualization to direct laryngoscopy and are non-inferior regarding time to intubation.

Methods

One hundred thirty-four patients (neonate to ten years of age, American Society of Anesthesiologists physical status I-III) scheduled for general surgical procedures were randomized to tracheal intubation using the Truview PCD or GlideScope video laryngoscope or direct laryngoscopy (Macintosh blade). The laryngoscopic view was scored using the Cormack-Lehane scale. Time to intubation (defined as the time from the moment the device entered the patient’s mouth until end-tidal CO₂ was detected) and the number of attempts were recorded.

Results

The Cormack-Lehane views attained using the GlideScope (P > 0.99) and Truview PCD (P = 0.18) were not superior to the views attained with direct laryngoscopy. Furthermore, the view attained using the GlideScope was significantly worse than that attained using direct laryngoscopy (P < 0.001). Fewer patients showed Cormack-Lehane grade I views with the GlideScope than with the Truview PCD (14% vs 82%, respectively; 95% confidence interval [CI] ?91% to ?46%). The observed median [Q1, Q3] times to intubation were: 39 [31, 59] sec, 44 [28, 62] sec, and 23 [21, 28] sec with the GlideScope, Truview PCD, and direct laryngoscopy, respectively, with median differences of 14 sec (95% CI 7 to 26, GlideScope – direct laryngoscopy) and 17 sec (95% CI 6 to 28, Truview PCD – direct laryngoscopy).

Conclusion

The Cormack-Lehane views attained using the GlideScope and the Truview PCD video laryngoscopes were not superior to views attained using direct laryngoscopy. Visualization with the GlideScope was significantly worse than with direct laryngoscopy. Use of the GlideScope and Truview PCD systems should be restricted to patients with specific indications.     

A reinforced suture line prevents recurrence after fundoplication in patients with familial dysautonomia

Background/Purpose

Long-term follow-up of fundoplication in patients with familial dysautonomia (FD) has revealed a high rate of recurrent gastroesophageal reflux. This may be because of the unique characteristics of patients with FD which include autonomic denervation accompanied by cyclic vomiting and retching. We reviewed our results with adaptations to the Nissen fundoplication to determine which would be most effective in preventing the need for reoperation.

Methods

We reviewed the records of 108 patient with FD who underwent fundoplication by a single pediatric surgeon from November 1978 to July 1, 2004. Patients were divided into 4 groups based on the operative technique: standard Nissen fundoplication, Nissen with a posterior gastropexy, Nissen with posterior gastropexy and a superior anchoring suture, and Nissen with a reinforced suture line in addition to the previous modifications. Demographic data and surgical outcomes were abstracted.

Results

Patients who underwent a Nissen fundoplication with a reinforced suture line were significantly less likely to require a reoperation for recurrent reflux than any other patients (P = .05, Fisher's Exact test) despite the fact that they were younger than patients who underwent a standard Nissen alone.

Conclusion

The addition of a reinforced suture line to the standard Nissen fundoplication decreases the failure rate for patients with gastroesophageal reflux and FD. A reinforced suture line may be an attractive modification for patients where the fundoplication may be under continued physical stress caused by autonomic perturbations, or other conditions such as uncontrolled seizures or progressive neurologic decline.     

Sustainability of mechanically lengthened bowel in rats

Introduction

It has been shown that the length of an intestinal segment may be doubled by applying gradual mechanical stretching. This study evaluated whether the lengthened intestinal segment retained the structure and function after the stretching device was removed.

Methods

A 1.5-cm jejunal segment was separated from intestinal continuity in 20 rats. After advancing a screw into the isolated jejunal segment by 5 mm 3 times a week until it was stretched by 3 cm, the screw was removed. Three weeks later, the jejunal segments were retrieved for analyses. Comparisons were made between the lengthened jejunal segments.

Results

The jejunal segment doubled its length after gradual stretching and retained this length 3 weeks after the screw removal (3.1 ± 0.8 vs 3.2 ± 0.4 cm, P > .05). The villous height, the muscular thickness, and the total alkaline phosphatase and lactase activities of the stretched jejunal segments were also unchanged 3 weeks after the screw removal.

Conclusions

Mechanical force induced the sustained lengthening of isolated jejunal segments in rats. The histologic and enzymatic alterations also persisted 3 weeks after the mechanical force was removed. This phenomenon may provide a novel method for the treatment of short bowel syndrome.     

Comparison of Macintosh and Airtraq(TM) laryngoscopes in obese patients placed in the ramped position

This study compared intubation conditions produced by the Macintosh and Airtraq^TM laryngoscopes when used in obese patients in the ramped position. One hundred and thirty‐two patients having bariatric surgery were placed in the ramped position and randomly assigned to have their tracheas intubated using either the Macintosh (n = 64) or an Airtraq (n = 68) laryngoscope. Mean (SD) intubation times were 37 (23) s and 14 (3) s for Macintosh and Airtraq, respectively (p < 0.0001). Compared with the Macintosh laryngoscope, the Airtraq laryngoscope provided an improved vocal cord view as assessed by the Cormack and Lehane score (number of patients with Cormack‐Lehane scores of 1/2/3/4/37/20/4/3 for the Macintosh, and 65/3/0/0 for the Airtraq laryngoscopes, p < 0.0001). One patient in the Macintosh group had a failed intubation and intubation was achieved with the Airtraq. For obese patients in ramped position, Airtraq affords faster tracheal intubation than the Macintosh laryngoscope.     

The pleural and human fibrin glue sandwich: a quick and effective post-pneumonectomy bronchial stump coverage technique

Background

Protection of the bronchial stump after pneumonectomy reduces the incidence of bronchopleural fistula. However, which technique provides the most satisfactory results remains open for debate.

Materials and Methods

We describe a study in which a bronchial stump coverage technique was performed using 2 layers of human fibrin glue (Tissucol; Baxter, Deerfield, IL USA) with an interposed patch of parietal pleura. From July 2005 to June 2007, this technique was used in 31 consecutive patients after standard pneumonectomy by a single surgeon.

Results

None of the patients developed early or late bronchopleural fistula, and no clinical adverse reaction was recorded. During the same period, alternative stump coverage techniques were used by different surgeons in 71 pneumonectomies. In this group, the rate of fistula was 6% (4 patients).

Conclusion

These preliminary data demonstrate the feasibility of the technique and suggest that it is at least equivalent to the other type of flaps used. The main advantages of this technique are the restoration of the natural separation between the mediastinum and pleural cavities, as well as the reduced operating time (duration 5 minutes).     

Comparison of the C‐MAC® videolaryngoscope with the Macintosh,Glidescope®, and Airtraq® laryngoscopes in easy and difficult laryngoscopy scenarios in manikins

The C‐MAC^® comprises a Macintosh blade connected to a video unit. The familiarity of the Macintosh blade, and the ability to use the C‐MAC as a direct or indirect laryngoscope, may be advantageous. We wished to compare the C‐MAC with Macintosh, Glidescope^® and Airtraq^® laryngoscopes in easy and simulated difficult laryngoscopy. Thirty‐one experienced anaesthetists performed tracheal intubation in an easy and difficult laryngoscopy scenario. The duration of intubation attempts, success rates, number of intubation attempts and of optimisation manoeuvres, the severity of dental compression, and difficulty of device use were recorded. In easy laryngoscopy, the duration of tracheal intubation attempts were similar with the C‐MAC, Macintosh and Airtraq laryngoscopes; the Glidescope performed less well. The C‐MAC and Airtraq provided the best glottic views, but the C‐MAC was rated as the easiest device to use. In difficult laryngo‐scopy the C‐MAC demonstrated the shortest tracheal intubation times. The Airtraq provided the best glottic view, with the Macintosh providing the worst view. The C‐MAC was the easiest device to use.     

Utility of amylase and lipase as predictors of grade of injury or outcomes in pediatric patients with pancreatic trauma

Introduction

Grade of injury, serum amylase, and lipase are markers used to assess pancreatic injury. It is unclear how amylase and lipase relate to grade of injury or predict outcome. We hypothesize that serum amylase and lipase are good predictors of grade of injury and outcomes in patients with pancreatic trauma.

Methods

This study is a multicenter review from 9 pediatric trauma centers of all children admitted to their institution over 5 years with a pancreatic injury. Initial as well as peak amylase and lipase values were analyzed with relation to pancreatic grade, length of stay, and outcomes.

Results

One hundred thirty-one records were analyzed. There were 44 girls and 85 boys with an average age of 9.0 ± 0.4 years. The mean injury severity score (ISS) score was 15.5 ± 1.2 SE. The average length of stay (in days) was analyzed by grades 0 (3.93), 1 (7.73), 2 (13.4), 3 (18.4), 4 (31), and 5 (13.5). Neither initial nor peak amylase/lipase correlated with grade of injury. Neither amylase nor lipase predicted length of stay or mortality. Maximal amylase was highly predictive of developing a pseudocyst.

Conclusion

There seems to be limited value for repetitive routine amylase and lipase levels in the management of pediatric trauma patients with pancreatic injury.     

Early experience with minimally invasive repair of congenital diaphragmatic hernias: results and lessons learned

Background:

Minimally invasive surgery (MIS) for the repair of congenital diaphragmatic hernias (CDH) had been described. This report reviews the authors’ experience with MIS repairs of CDH and discusses the technical development of this approach.

Methods:

From 1999 until now, the authors collected data on children who underwent an MIS approach for CDH repair.

Results:

Seventeen children (11 Morgagni and 7 Bochdalek) had undergone an attempt at MIS repair. All Morgagni defects were treated successfully using laparoscopy (mean age, 28 ± 31 months). Mean follow-up was 22 ± 9 months. There was 1 recurrence. Four children with Bochdalek CDH were treated as newborns (range, 3 to 21 days), and 3 had operations later (4, 11, and 32 months). The first repair was attempted initially transabdominally and was converted to a thoracoscopic approach. The rest of the Bochdalek repairs were performed thoracoscopically. Bochdalek repairs via MIS were successful in 3 children (2 older children and 1 neonate). No child had pulmonary hypertension. Two of the 3 Bochdalek patients did well postoperatively (follow-up, 18 +/− 7 months); the last patient experienced recurrence 11 months after repair.

Conclusions:

MIS for CDH is ideal for Morgagni defects. It should be considered for nonnewborns with a Bochdalek CDH. The MIS approach for a newborn with a CDH cannot be recommended because of the high failure rate and frequent rise in Pco₂ levels.