Airway management data show

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comaparative study between Airtraq and McGrath VL and Classic Macintosh in patients with neck collar in place and neutral position

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Airway management data show

  1. 1. Airway Management: A Comparative Study Using McGrath® Video laryngoscope versus Airtraq® and Macintosh Laryngoscope in Neutral Position.
  2. 2. Presented by Alaa Elsayed Goma Falogy M.Sc. Assistant lecturer of Anaesthesia and Surgical Intensive care Faculty of medicine Zagazig University
  3. 3. Under supervision of Prof. Dr. Ayman Abdel El-Salam Hassan Professor of Anesthesia and surgical Intensive Care Prof. Dr. Ahmed Abd El-Hakim Balata Professor of Anesthesia and surgical Intensive Care Prof. Dr. Khaled Mohammed El-Sayed Professor of Anesthesia and surgical Intensive Care
  4. 4. I would like to thank…. Prof, Dr.: Salah A. Fattah Ismail For his sincere effort to travel all this distance to give us this honor to be with us this special day
  5. 5. I would like to thank…. Prof, Dr.: Ahmed M. Salama For his pleased acceptance to share us this discussion
  6. 6. I would like to thank…. to my precious family; you mean the world to me you'll always be my strength, my power, thank you for being a part of me...
  7. 7. Research question If used by [experienced anesthiologists] who is managing a model of a difficult airway in form of neck immobilization by semi- rigid neck collar Do [ the Airtraq OL and the McGrath VL] Are more safe and more effective in tracheal intubation when compared to [Classic Macintosh laryngoscope]?
  8. 8. Introductio n
  9. 9. • Airway management is a major challenge for the anaesthesiologists in their everyday operative practice using direct laryngoscopy. • During this direct laryngoscopy, positioning of the head and neck in neutral position • will decrease chance of optimal laryngeal visualization which impair the line of sight between laryngeal , pharyngeal and oral axes.
  10. 10. Concept of line of sight during direct laryngoscopy
  11. 11. • patients with cervical spine instability who necessitate neck immobilization , airway management implies upon a high risk of neurological damage related to head and neck manipulation, so semi-rigid neck collar is applied in trail to control neck movement. • Such immobilisation technique can turn intubation process under the direct laryngoscopy into more difficult situation (Impair the line of sight) .
  12. 12. • These concerns have aroused the idea to develop number of alternatives to classical Macintosh laryngoscope such as Airtraq® Optical Laryngoscope, McGrath® Video laryngoscope. • These laryngoscopes do not require the arrangement of pharyngeal, laryngeal and oral axis in one line of sight and thus do not require modulation of neutral position. • During difficult airway situations, both Airtraq optical laryngoscope and McGrath Video laryngoscope sound to be better than Macintosh laryngoscope
  13. 13. in stimulated difficult intubation situations in patients with their cervical spine kept in neutral position by semi-rigid neck collar as an immobilization techniques. VS
  15. 15. Cervical spine stability  Cervical stability:  is the ability of the spine to maintain strong relationships between vertebrae, so as not to damage the neural structures contained within the spinal column Cervical instability: Excess translational or rotational motion of any vertebra and means that the odontoid process is no longer firmly held against the back of the anterior arch of C1.
  16. 16. Concept of Videolaryngoscopy Video laryngoscopy (VL) is an update of high resolution micro-cameras systems that improves the success rate of intubation.  There is a hypothesis that improved lighting and a better view can increase the chance of intubation success.  Anaesthesia had used the miniature camera for many years but for only bronchial endoscopy .
  17. 17. Video Laryngoscopy in difficult Airway management VIDEO ASSISTED LARYNGOSCOPY AS AN INTIAL APPROACH TO INTUBATION
  18. 18. McGrath Video- Laryngoscope
  19. 19. The McGrath Video Laryngoscope: (Aircraft Medical, Edinburgh, United Kingdom) • A video-based system for tracheal intubation that utilizes a video camera embedded into a camera stick. • The unit is a battery powered Features a single electronic control • Offers the user an image of the Glottis and the surrounding anatomy on a LCD screen. • The unit which is used as a part of much the same way as common as Macintosh laryngoscope
  20. 20. Concept of the improved glottic view Based upon the hypothesis that improved glottic view leads the better chance of successful intubation
  21. 21. Airtraq Optical-Laryngoscope
  22. 22.  based on refraction prism principle to give an angular view of the glottic area.  The blade of the Airtraq consists of two side by side channels.  One channel act as housing for the ETT, and the other channel terminates in terminal lenses and transmit back the image.  The viewed image is then been transmitted to a proximal eye piece viewfinder employing a prisms system and lenses not as basic concepts of usual fiberoptics. AIRTRAQ Optical Laryngoscope:
  24. 24. METHODOLOGY  This was a prospective, randomized clinical trial.  group assignments (C, A and M)  age group of 20-50 years, ASAps Grades I or II undergoing elective surgery requiring general Anaesthesia  three groups of 50 patients each , of either sex.  All patients received standard monitoring according to ASA guidelines.
  25. 25. INTUBATION PROCEDURE  Intubation process was performed by one anesthesiologist with accepted experience in two recent video laryngoscopes under study.  A malleable stylet was used in both groups (Classical Macintosh and McGrath VL).  The technique was considered failed if tracheal intubation was not achieved within 120 seconds or within a maximum of three intubation attempts.
  27. 27. INTUBATION PROCEDURE  Intubation time was separated into T1 and T2. T1 is the time between insertions of the allocated laryngoscope in the mouth until optimal glottic view including optimization maneuvers. T2 is the time from optimal glottic view till confirmation of tracheal intubation (by vision) including removal of the device.
  29. 29. Intubation sequence by McGrath VL  With the patient in neutral position, use left hand to introduce the VL into the midline of the oropharynx.  Push the blade tip till it past the posterior portion of the tongue.  Then turn eyes to the video screen in order to obtain the best view of the glottis.  The video image of the glottis now is representing Cormack – Lehane view.  Using LCD screen, the ETT is then advanced on a smooth curve through the glottis mediated by stylet.
  30. 30. Intubation sequence by McGrath VL introduce the VL into the midline of mouth and Push the blade tip till posterior portion of the tongue.
  31. 31. Intubation sequence by McGrath VL turn eyes to the video screen in order to obtain the best Cormack – Lehane view.
  32. 32. Intubation sequence by McGrath VL By use of LCD screen, the ETT is then advanced on a smooth curve through the glottis by stylet.
  34. 34. Intubation sequence by Airtraq OL  Add lubricant to outer surface of the endotracheal tube and hosting channel of Airtraq OL.  Embed the tube into the side holding channel of the Airtraq so that the tip of the endotracheal tube is at the tip of the side channel.  Turn on the light for about 30-60 seconds before the procedure.
  35. 35. Intubation sequence by Airtraq OL  The device is held in the mouth in the midline by right hand .  Then advanced by sliding over the tongue.  The image on view finder is optimized by moving the blade as necessary by left hand.  The laryngeal inlet must be in the centre of viewfinder just before pushing the ETT forward by right hand .
  36. 36. Intubation sequence by Airtraq OL Loading ETT to hosting channel Introduction into oral cavity
  37. 37. Intubation sequence by Airtraq OL Sliding over the tongue Checking the viewfinder and ETT insertion
  38. 38. Intubation sequence by Airtraq OL Unholding the ETT from the Airtraq Removal of the Airtraq
  39. 39. RESULTS
  40. 40. PARAMETERS TO BE COMPARED BETWEEN ALL GROUPS  Demographic data and Airway assessment data.  Intubation Conditions:  Numbers of Attempts.  Optimization Procedures.  Cormack - Lehane score.  Intubation Difficulty Score.  Success Rate of Intubation.  Time To Intubation.  Hemodynamics (HR and MAP).  Complications.
  41. 41. DEMOGRAPHIC AND AIRWAY ASSESSMENT DATA Demographic data Group C Group A Group M p-value (Sig.) (N=50) (N=50) (N=50) Age (in years) 35.90±7.65 35.92±7.70 35.16±7.72 0.856** (NS) Male / Female 62 / 38 % 66 / 34 % 60 / 40 % 0.892* (NS) Height (cm) 171.48±3.71 171.62±3.54 171.6±3.8 0.981** (NS) Weight (Kg) 77.96±7.22 77.62±6.25 76.86±6.93 0.619** (NS) BMI (Kg/m2 ) 26.84±2.29 27.06±2.05 26.14±2.13 0.095** (NS) ASAps I / II 14 / 86 % 16 / 84 % 10/ 90 % 0.668* (NS) MS I / II 56 / 44 % 48 / 52 % 62 / 38 % 0.369* (NS) TMD (cm) 7.18±0.34 7.12±0.34 7.17±0.32 0.766** (NS) NON- SIGNIFICANT
  42. 42. NUMBERS OF ATTEMPTS Macintosh group Airtraq group McGrath group Most of patients in VL need 1 attempt for successful intubation About 1/3 patients needed 2nd and 3rd attempt in Macintosh group HS
  43. 43. OPTIMIZATION PROCEDURE Highly Significant
  44. 44. CORMACK-LEHANE SCORE 46 Airtraq almost get C&L I MacintoshleastinC&LI PERSIST Most views of McGrath C&L II Macintosh most C&L II HIGHLY- SIGNIFICANT
  45. 45. IDS DISTRIBUTION AirtraqmaxIDSis2 McGrathmaxIDSis4 MacintoshreachedIDS7 HIGHLY- SIGNIFICANT
  49. 49. ALL Increased MAP ALL return to basal level HEMODYNAMICS (MAP) NON- SIGNIFICANT
  50. 50. Time to Intubation 52 Familiarity and same technique HIGH SIGNIFICANT 3 2 1 3 1 2
  51. 51. Complications Sharp tip for both devices produce more trauma as primary insult more than secondary injury Stylet manipulation?? Primary > secondary Secondary is more than primary
  52. 52. LIMITATIONS DESIGN Operator knows the devices, which may also introduce bias. (solved by closed envelopes basis (lottery technique)). STIMULATIVE Not on real cervical trauma patients. FURTHERMORE, Inter-incisor distance may be added in airway assessment parameters as pre and post insertion of neck collar especially because it affects primary insertion of Airtraq OL.
  54. 54. Research question Are McGrath® Video laryngoscope versus Airtraq more safe and more effective in tracheal intubation when compared to Classic Macintosh laryngoscope in patients with neck collar inserted?
  55. 55. Airtraq OL and McGrath VL showed the prove beyond doubt to be safer and more effective than Macintosh Laryngoscope in managing stimulated difficult intubation situation in form of cervical spine immobilization.
  57. 57. The use of videolaryngoscopes in our daily practice is recommended specially in difficult airway scenarios and similar studies need to be done upon real cervical trauma patients for better assessment of its advantages and disadvantages.
  58. 58. THANK YOU