Scandinavian SSAI clinical practice guideline on pre‐hospital airway management
Marius RehnPer Kristian HyldmoViðar MagnússonJouni KurolaPoul KongstadLeif RognåsLene Kristine JuvetMärten Sandberg
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Background The Scandinavian society of anaesthesiology and intensive care medicine task force on pre‐hospital airway management was asked to formulate recommendations following standards for trustworthy clinical practice guidelines. Methods The literature was systematically reviewed and the grading of recommendations assessment, development and evaluation ( GRADE ) system was applied to move from evidence to recommendations. Results We recommend that all emergency medical service ( EMS ) providers consider to: apply basic airway manoeuvres and airway adjuncts (good practice recommendation); turn unconscious non‐trauma patients into the recovery position when advanced airway management is unavailable (good practice recommendation); turn unconscious trauma patients to the lateral trauma position while maintaining spinal alignment when advanced airway management is unavailable [strong recommendation, low quality of evidence (QoE)]. We suggest that intermediately trained providers use a supraglottic airway device ( SAD ) or basic airway manoeuvres on patients in cardiac arrest (weak recommendation, low QoE). We recommend that advanced trained providers consider using an SAD in selected indications or as a rescue device after failed endotracheal intubation ( ETI ) (good practice recommendation). We recommend that ETI should only be performed by advanced trained providers (strong recommendation, low QoE). We suggest that videolaryngoscopy is considered for ETI when direct laryngoscopy fails or is expected to be difficult (weak recommendation, low QoE). We suggest that advanced trained providers apply cricothyroidotomy in ‘cannot intubate, cannot ventilate’ situations (weak recommendation, low QoE). Conclusion This guideline for pre‐hospital airway management includes a combination of techniques applied in a stepwise fashion appropriate to patient clinical status and provider training.Keywords:
Guideline
Clinical Practice
Background: It has been observed that laryngoscopy and intubation leads to profound cardiovascular effects along with an increase in catecholamine concentrations. Multiple studies have been conducted to attenuate the same. McCoy blade has been found to decrease this pressor response as compared to the Macintosh blade used routinely. Therefore, a comparative study of heart rate (HR) and mean arterial pressure (MAP) changes during laryngoscopy and intubation using these two blades was conducted to establish the same. Methods: The study included 200 patients divided into two groups of 100 each. Laryngoscopy and intubation was performed either with Macintosh or McCoy blade. The HR and MAP were recorded at every 1 minute interval during laryngoscopy and intubation for 5 minutes. Apart from above observations, Mallampatti classification (MPC), Cormack and Lehane classification (C& L) and time required for intubation were noted. Results: There was no difference in baseline HR and MAP in both the groups i.e. Macintosh (MK) and McCoy (MY) . The percentage rise from baseline HR and MAP in MK group was highly significant during laryngoscopy and intubation and 1 minute after that as compared to MY group. Similarly, comparison of HR and MAP changes between both the groups revealed highly significant decrease in the parameters in MY group, during laryngoscopy and intubation and 1 minute after the procedure. No other complications of laryngoscopy & intubation were observed in our study. Conclusion: McCoy blade, primarily devised for difficult intubation has additional benefit of alleviating the pressor response to laryngoscopy and intubation. We recommend its use in patients with cardiovascular compromise, raised intracranial tension (ICT), apart from its established indications. Abbreviations: HRHeart Rate, MAPMean Arterial Pressure, ICT – Intracranial tension
Pressor response
Mean arterial pressure
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Summary Background Some techniques used to achieve intubation in children predicted to have a difficult airway do not involve direct laryngoscopy or assessment of the laryngeal grade. Direct laryngoscopy may therefore be performed immediately after intubation to provide a record for future anesthetics. It is unknown whether this postintubation grade accurately reflects the standard laryngeal grade in this group. Aim The aim of the study was to identify those children who were predicted to be a difficult intubation and to perform direct laryngoscopy before and after intubation. We set out to ascertain if direct laryngoscopy performed after intubation could accurately predict the standard un‐intubated laryngeal grade in this group. Methods All children presenting for general anesthesia who were clinically predicted to be a difficult intubation were considered for this study and prospectively recruited. After induction of anesthesia, one study anesthetist performed direct laryngoscopy before and another study anesthetist then performed direct laryngoscopy after intubation. These laryngeal grades were then compared. Results A total of 21 children were successfully recruited and studied, and all patients were successfully intubated. Overall, the postintubation grade did not reliably reflect the standard grade, but did not differ by more than one grade in any patient. In one‐third of subjects, the postintubation grade was equal to the standard grade, in one‐third it was a grade ‘easier’ and in one‐third a grade ‘harder’. Conclusion Assessment and documentation of a postintubation laryngeal grade does not appear to provide reliable information for future anesthetics and may even have the potential to be misleading. Any such documentation should always refer to the presence of an endotracheal tube and be interpreted with caution.
Laryngeal Diseases
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We read with interest the study by Tong et al. [1] and would like to make some comments. The authors found that there was a greater increase in blood pressure in the laryngoscope-assisted fibreoptic intubation group (10% and 33% after laryngoscopy and intubation, respectively) compared with the lingual traction group. It has been shown in a previous study by Smith et al. [2] that the application of lingual traction to assist fibreoptic intubation caused a significantly greater and more prolonged cardiovascular response than intubation using a Macintosh laryngoscope. In our study we compared jaw thrust and direct laryngoscopy as an aid to fibreoptic intubation [3]. We found no significant difference in heart rate and blood pressure between these two groups. We agree with Tong et al. that responses to laryngoscopy can have an adverse effect in susceptible patients; however, the rise in blood pressure was observed mainly after intubation. The increase in blood pressure is therefore more likely to be an effect of passing a tube into the trachea. The fact that they observed a greater increase in blood pressure in the laryngoscopy group could be related to different types or levels of anaesthesia used compared with the other studies or, indeed, different patients' responses to laryngoscopy and intubation. We believe that laryngoscope-assisted fibreoptic intubation is a very useful technique, particularly in cases with unanticipated difficult intubation. We are concerned that by focusing on the effects of the pressor response to laryngoscopy and intubation (which can simply be obtunded with various methods) a useful method of managing a difficult airway could be discouraged.
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Background: Laryngoscopy and endotracheal intubation is an integral part of general anesthesia. Endotracheal intubation involving conventional laryngoscopy produces a haemodynamic changes associated with increased heart and blood pressure. The aim of the present study was to compare the hemodynamic changes that occur during and after endotracheal intubation with either a conventional (Macintosh) laryngoscope or a video laryngoscope in patients who are ASA grade I and II.Methods: After getting approval from ethics committee and consent form from each patients 120 patients with age between 18-65 years of ASA-I, II grade were included in the study. They were divided into two groups. Group A was underwent with tracheal intubation with the Macintosh blade (size 3 blade and size 4) and group B with AWS (Pentax) video laryngoscope. The time taken to perform endotracheal intubation and haemodynamic changes associated with intubation were noted in both the groups at different time points.Results: The duration of laryngoscopy and intubation was significantly longer in group B (video laryngoscopy) when compared to group A patients. However, haemodynamic changes did not showed any significant differences between the groups.Conclusions: Video laryngoscopy did not offer any advantages in terms of haemodynamic response to laryngoscopy and intubation in patients when compared with conventional ones.
Haemodynamic response
Endotracheal intubation
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Background and objective Several studies have shown that videolaryngoscopes can provide better laryngeal exposure than conventional laryngoscopy. These studies, however, did not exclusively focus on patients with an anticipated difficult intubation. The aim of the present study was to assess whether a videolaryngoscope would provide better laryngeal exposure than conventional laryngoscopy and therefore facilitate intubation in cases of difficult laryngoscopy. Methods One hundred and twelve patients with an estimated difficult intubation, scheduled to undergo surgical operations, requiring general anaesthesia and endotracheal intubation, were included in the study. Direct laryngoscopy with a Macintosh blade was performed, followed by videolaryngoscopy and intubation attempt(s). The laryngeal views obtained by each method were recorded according to the Cormack/Lehane scale. Results The percentage of Cormack–Lehane I and II views obtained by conventional laryngoscopy rose from 63.4 to 90.2% (P < 0.0005) with videolaryngoscopy, whereas Cormack–Lehane III and IV views declined from 36.6 to 9.8% (P < 0.0005). Intubation was successful in 98.2% of the cases. Conclusion In patients with an anticipated difficult airway, videolaryngoscopy significantly improved the laryngeal exposure thus facilitating endotracheal intubation.
Laryngoscopes
Endotracheal intubation
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Introduction: As is well described laryngoscopy and intubation produce significant hemodynamic response. It is shown in previous studies that type of laryngoscope blade used affects the degree of hemodynamic response to endotracheal intubation. In our study we have attempted to compare hemodynamic response to laryngoscopy and intubation using Macintosh and McCoy blade. Aim: Our aim was to perform comparative study of hemodynamic response to laryngoscopy and intubation using Macintosh versus McCoy blade. Materials and Methods: A prospective randomized controlled study comparing hemodynamic response to laryngoscopy and intubation using Macintosh and McCoy blade was conducted. A total no. of Sixty patients, either male or female, between age group of 20 -50yrs, belonging to American Society of Anaesthesiology physical status I and II requiring General anaesthesia were randomly allocated to either group A (Macintosh group) or group B (McCoy group) In both the groups, standard methods were used. Comparison of hemodynamic parameters i.e. Heart rate (HR), systolic (SBP) diastolic (DBP) and mean blood pressure (MAP) was done at induction, during laryngoscopy and intubation, till 5 mins after intubation. Statistical Analysis: Hemodynamic changes in between the two groups were compared statistically using Unpaired “t” tests. Results: Significant rise in all HR, SBP, DBP, MAP was seen in both the groups after laryngoscopy and intubation. In group A the rise was found to be statistically significant as compared to group B. Conclusion: This study helped us to conclude that McCoy blade produces reduced hemodynamic response to laryngoscopy and intubation as compared to Macintosh blade. Keywords: Hemodynamic response, Intubation, Laryngoscopy, Macintosh and McCoy blade.
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The screening tests used for pre-operative evaluation of airway to predict difficult laryngoscopy and intubation have variable diagnostic accuracy. The unanticipated poor laryngeal view is gold standard for defining difficult intubation. We aimed to find out the prevalence of difficult laryngoscopy and intubation, which airway parameter better predicts difficult intubation and whether difficult laryngoscopy is associated with difficult intubation or not.This analytic cross sectional study was conducted in 665 ASA I/II adult patients, aged 18-65, without obvious airway pathology undergoing elective surgery under general anesthesia. The pre-operative screening tests included mouth opening, modified mallampatti, ratio of height to thyromental distance, sternomentaldistance and upper lip bite test. Cormack-Lehane grade III/ IV was defined as difficult laryngoscopy and potentially difficult intubation. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy and area under curve at 95% confidence interval was calculated for all five screening tests.The prevalence of difficult laryngoscopy and intubation was 6.6% (44 cases). The upper lip bite test because of its highest specificity, positive predictive value, negative predictive value, accuracy and area under curve (99.7%; 93.9%; 99.7%; 95.2%; 85.1% respectively) with moderate level of sensitivity (70.5%) was better predictor of difficult intubation than other tests. The difficult laryngoscopy was associated with difficult intubation (p=0.00).The prevalence of difficult laryngoscopy and intubation was 6.6%.The upper lip bite test was a better predictor of difficult intubation and there was a significant association of difficult laryngoscopy with difficult intubation.
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Elective surgery
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We evaluated the efficacy of intubation over a gum-elastic bougie by using either a blind technique or indirect laryngoscopy with a laryngeal mirror in patients with unexpected difficult direct laryngoscopy. In a prospective study, 60 consecutive patients with an unexpected Grade III or IV direct laryngoscopy were randomly allocated for intubation with a gum-elastic bougie either blindly (Group 1) or by indirect laryngoscopy with a laryngeal mirror (Group 2). We evaluated the failure rate of each method of intubation, complications related to either method, and the time required for intubation. Out of 725 patients evaluated over a 2-mo period, 60 patients (8.3%) had a Grade III laryngoscopy, and 30 of these were randomized into each group. There were 8 failed intubations in Group 1 compared with 1 failed intubation in Group 2 (P < 0.05). All eight failures in the blind intubation group ended with esophageal intubation. No additional complications were noted in either group. The time required for endotracheal intubation with each group was not significantly different (45 ± 10 s versus 44 ± 11 s). We conclude that intubation with a gum-elastic bougie had a lower failure rate using indirect laryngoscopy with a laryngeal mirror than a traditional blind technique.
Endotracheal intubation
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Study Objective Video laryngoscopy has primarily been developed to assist in difficult airways. Using video laryngoscopy in pediatric airway management is an up-and-coming topic. The aim of the presented study was to compare the intubation conditions obtained when using the C-MAC video laryngoscope with Miller blades sizes 0 and 1 for standard direct laryngoscopy and indirect laryngoscopy in children weighing less than 10 kg. Design This was a prospective study. Setting The study was performed in a university hospital. Patients Following ethical approval, 86 infants weighing less than 10 kg and undergoing surgery under general anesthesia were studied prospectively. Intervention Indirect and direct laryngoscopy either with C-MAC Miller blade size 0 or size 1. Measurements First, direct laryngoscopy was performed, and the best obtained view was graded without looking at the video monitor. A second investigator blinded to the view obtained under direct laryngoscopy graded the laryngeal view on the video monitor. Time to intubation, intubation conditions, and intubation attempts were recorded. Results In infants less than 10 kg, intubation conditions were excellent. There were no significant differences between the use of Miller blade 0 or 1 in reference to Cormack-Lehane grade, time to intubation, time to best view, or intubation attempts. Comparing direct and indirect intubation conditions using either Miller blade 0 or 1 revealed that the use of indirect laryngoscopy provided a significantly better view ( P < 0.05) of the vocal cords. In 3 infants weighing more than 8 kg, the Miller blade 0 was described as too short and narrow for intubation. Conclusions Both devices allowed for an excellent visualization of the vocal cords.
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Objectives/Hypothesis The anatomy of children with severe Pierre Robin sequence can present a challenge for direct laryngoscopy and intubation. Advanced techniques including flexible fiberoptic laryngoscopic intubation have been described but require highly specialized skill and equipment. Rigid video laryngoscopy is more accessible but has not been described in this population. Study Design Retrospective cohort study. Methods A retrospective review was completed at a tertiary care center of all children between January 2016 and March 2020 with Pierre Robin sequence who underwent a mandibular distraction osteogenesis procedure. Intubation events were collected, and a descriptive analysis was performed. A univariate logistic regression model was applied to direct laryngoscopy and flexible fiberoptic laryngoscopy with rigid video laryngoscopy as a reference. Results Twenty‐five patients were identified with a total of 56 endotracheal events. All patients were successfully intubated. Direct laryngoscopy was successful at first intubation attempt in 47.3% (9/19) of events. Six direct laryngoscopy events required switching to another device. Rigid video laryngoscopy was successful at first intubation attempt in 80.5% (29/36) of events. Two cases required switching to another device. Flexible fiberoptic laryngoscopy was found successful at first intubation attempt in 88.9% (8/9) of events. Direct laryngoscopy was 4 times more likely to fail first intubation attempt when compared to rigid video laryngoscopy ( P < .05). There was no significant difference between rigid video laryngoscopy and flexible fiberoptic laryngoscopy for intubation. Conclusions For children with Pierre Robin sequence rigid video laryngoscopy should be considered as a first attempt intubation device both in the operating room and for emergent situations. Level of Evidence 4 Laryngoscope , 131:1647–1651, 2021
Pierre Robin syndrome
Laryngoscopes
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