airway management data show by alaa holiel summary

Airway management :

Comparative study between McGrath VL and Airtraq OL

VS Macintosh laryngoscope in neutral neck position

Presented byAlaa Elsayed Goma

FalogyM.Sc. of Anaesthesia and surgical intensive care

Faculty of medicine Zagazig university

2016

Under supervision of

Prof; Ayman Abdel El-Salam Hassan

Professor of Anesthesia and surgical Intensive Care

Prof; Ahmed Abd El-Hakim Balata

Professor of Anesthesia and surgical Intensive Care

Prof; Khaled Mohammed El-

Sayed Professor of Anesthesia and surgical

Intensive Care

Research questionIfused by [experienced anesthiologists] managing a model of a difficult airway in form of neck immobilization by semi- rigid neck collarDo [ the Airtraq OL and the McGrath VL] Are [more safe and more effective in tracheal intubation ] when compared to [Classic Macintosh laryngoscope]?

Introduction

INTRODUCTION:• 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.

Concept of line of sight during direct laryngoscopy:

INTRODUCTION:• 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) .

INTRODUCTION:

INTRODUCTION:• These concerns have aroused the idea to

develop number of alternatives to classical Macintosh laryngoscope such as Airtraq ® OL, 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

AIM OF THE WORK To evaluate the efficacy and safety of :

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

Neck extension During intubation may badly affects the cervical instability and this is may imply upon risk of spinal cord injury

NECK EXTENSION

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.

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 .

Video Laryngoscopy in difficult Airway management:

McGrath Video-Laryngoscope

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

Concept of the improved glottic view

Based upon the hypothesis that improved glottic view leads the better chance of successful intubation

AIRTRAQ Optical Laryngoscope

AIRTRAQ Optical Laryngoscope

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.

PATIENTS AND

METHODS

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 will receive standard monitoring according to ASA guidelines.

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.

CORMACK & LEHANE SCORE

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.

McGrath VL;INTUBATION

TECHNIQUES AND SEQUENCE

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.

Now, move 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 video visualization, the ETT is then advanced on a smooth curve through the glottis mediated by styllet.




AIRTRAQ OL;INTUBATION TECHNIQUES

AND SEQUENCE

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.


Hold the device in the mouth in the midline by right hand .

advance by sliding the device over the tongue.

check the image on view finder to optimize the view by moving the blade as necessary by left hand.

Be sure that the laryngeal inlet is in the centre of viewfinder just before pushing the ETT forward by right hand .




RESULTS OF THE

STUDY

COMPARISON BETWEEN GROUPS ARE DONE

ACCORDING TO: INTUBATION CONDITIONS

NUMBERS OF ATTEMPTS Optimization Procedures Cormack and Lehane score IDS

SUCCESS RATE OF INTUBATION TIME TO INTUBATION HEMODYNAMICS COMPLICATIONS

DEMOGRAPHIC AND AIRWAY ASSESSMENT

DATADemographic 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)

DEMOGRAPHIC AND AIRWAY ASSESSMENT

DATA

Non-Significant

RESULTS OF THE STUDY

numbers of attempts

Macintosh group

Airtraq group

McGrath group

HS

RESULTS OF THE STUDY Cormack-Lehane score in each

group

43

Airtraq almost get C&L I

Mac

into

sh le

ast i

n C

&LI

Most views of McGrath C&L II

Macintosh most C&L II

HIGHLY- SIGNIFICANT


IDS DISTRIBUTION

Airt

raq

end

in

IDS

2

McG

rath

end

s in

ID

S 4

Mac

into

sh e

nds

in

IDS

7

HIGHLY- SIGNIFICAN

T


SUCCESSFULNESS

45

Mac

into

sh h

as 4

fa

ilure

s

NON-SIGNIFICAN

T


SUCCESSFULNESS

FAMILARITY &

ADAPTATION

Post-hoc inter-group analysis

47

BETTER IMAGE

CONCEPT THOERY SA

ME

VID

EOSC

OPE

EF

FIEN

CY

FAMILARITY

NO NEED FOR

ALIGNMENT

AIRTRAQ LEAST

MACINTOSH MOST

When it comes to intubation time?

50

Aga

in ..

Fa

mili

arit

y

RESULTS OF THE STUDY Complications Occurrence

Sharp tip for both devices produce

more trauma

as primary insult more than

secondary injury

Styl

et

man

ipul

atio

n

LIMITATIONS DESIGN

operator knows the devices, which may also introduce bias. (solved by closed envelopes basis).

STIMULATIVEnot 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.

SUMMARY AND

CONCLUSION

The conclusion of this study proves that Airtraq OL and McGrath VL are: MORE EFFECTIVE AND SAFE Than Macintosh Laryngoscope in managing stimulated difficult intubation situation in form of cervical spine immobilization by semi-rigid neck collar

RECOMMENDATIONS

This study recommends use of videolaryngoscopes in our daily practice specially in difficult airway scenarios such as neck immobilization situations because it provide better airway management even without extensive training, and it is needed to conduct similar studies upon real cervical trauma patients for better assessment of its advantages and disadvantages.

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

I would like to thank….

Prof, Dr.: Ahmed M. Salama

For his pleased acceptance to share us this discussion

I would like to thank…. My family that

suffered a lot through all this period of Ph.D. journey And they deserve all love and care

THANK YOU

airway management data show by alaa holiel summary

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