A multicentre randomised controlled trial of the McGrath™ Mac videolaryngoscope versus conventional laryngoscopy.

Before completion of this study, there was insufficient evidence demonstrating the superiority of videolaryngoscopy compared with direct laryngoscopy for elective tracheal intubation. We hypothesised that using videolaryngoscopy for routine tracheal intubation would result in higher first-pass tracheal intubation success compared with direct laryngoscopy. In this multicentre randomised trial, 2092 adult patients without predicted difficult airway requiring tracheal intubation for elective surgery were allocated randomly to either videolaryngoscopy with a Macintosh blade (McGrath™) or direct laryngoscopy. First-pass tracheal intubation success was higher with the McGrath (987/1053, 94%), compared with direct laryngoscopy (848/1039, 82%); absolute risk reduction (95%CI) was 12.1% (10.9-13.6%). This resulted in a relative risk (95%CI) of unsuccessful tracheal intubation at first attempt of 0.34 (0.26-0.45; p < 0.001) for McGrath compared with direct laryngoscopy. Cormack and Lehane grade ≥ 3 was observed more frequently with direct laryngoscopy (84/1039, 8%) compared with McGrath (8/1053, 0.7%; p < 0.001) No significant difference in tracheal intubation-associated adverse events was observed between groups. This study demonstrates that using McGrath videolaryngoscopy compared with direct laryngoscopy improves first-pass tracheal intubation success in patients having elective surgery. Practitioners may consider using this device as first choice for tracheal intubation.

Awake craniotomy in a super obese patient using high flow nasal cannula oxygen therapy (HFNC).

Super obesity with a body mass index (BMI) >50 kg/m2 presents a challenge for the neuroanesthesiologist during awake craniotomy procedures and poses increased perioperative risk of complications, even vis-à-vis morbid obesity. This article presents a super obese patient (BMI 57 kg/m2) with drug-refractory epilepsy and obstructive sleep apnea who underwent left anterior temporal lobectomy through awake craniotomy to preserve language and memory, using warmed humidified high flow nasal cannula (HFNC) oxygen therapy. Awake craniotomy was facilitated by the use of HFNC, which proved essential to prevent airway collapse by creating continuous positive airway pressure through high flow and facilitated intraoperative neurologic language and memory testing while maintaining adequate oxygenation.

The novel video-assisted intubating laryngeal mask Totaltrack compared to the intubating laryngeal mask Fastrach - a controlled randomized manikin study.

BACKGROUND: The novel Totaltrack combines a supraglottic airway device with video laryngoscopic tracheal intubation. The intubation laryngeal mask Fastrach is an established device without visual control of intubation. We hypothesized that supraglottic ventilation success with Totaltrack would be similar to Fastrach, but intubation would be performed faster due to visual control of the procedure. METHODS: Fifty-five anaesthesiologists were randomized into one of two study arms: Fastrach Totaltrack. After a standardized introduction, six consecutive attempts of supraglottic ventilation and intubation attempts with each of one of the devices were performed on an airway manikin. The combined primary outcome was: time to supraglottic ventilation and time to ventilation after intubation. Additionally, success rate and learning curves were evaluated. RESULTS: Supraglottic time to ventilation was shorter when using the Fastrach compared to the Totaltrack (median: 7.8 s [confidence interval [CI]: 7.0-8.6 s] vs. 11 s [CI: 7.8-14.2 s], P < 0.001). Intubation was faster using the Fastrach compared to Totaltrack (median: 12.5 s, [CI: 10.1-14.9 s] vs. 23.3 s [CI: 21.5-25.1 s], P < 0.001). Success rate for supraglottic ventilation was comparable between Fastrach and Totaltrack (86-96%). Successful intubation via the device was 100% in Fastrach and ranged from 61% to 93% in Totaltrack, with a higher probability of successful intubation after four applications. CONCLUSION: In this manikin-based study the novel Totaltrack did not prove superior to Fastrach despite a similar design. Video laryngoscopic control of supraglottic ventilation and endotracheal intubation was prolonged using the Totaltrack. Clinical trials are mandatory to evaluate the role of the Totaltrack in airway management.

[Airway management in intensive care units in Rhineland-Palatinate : Evolution over five years]. / Atemwegssicherung auf Intensivstationen in Rheinland-Pfalz : Entwicklung über fünf Jahre.

BACKGROUND: Securing the airway in severely ill patients is associated with a high rate of complications. So far, no information exists about the equipment readily available for airway management in German intensive care units (ICUs). It is also unknown if the range of material has improved over time. OBJECTIVES: In the present trial the availability of equipment for airway management in ICUs in Rhineland-Palatinate was evaluated at two different times. MATERIALS AND METHODS: Using a structured questionnaire, all ICUs in the state were contacted in the years 2010 and 2015. The availability of different types of equipment for airway management, as well as the presence of a training program for airway management, was evaluated. RESULTS: For 2010 data from 64 ICUs were evaluated and for 2015 data sets from 63 ICUs were collected. In 2010 indirect laryngoscopes were available in eight ICUs; in 2015 these devices were directly accessible in 43 units (p < 0.0001). Extraglottic devices were available in all but one ICU in 2010 and all ICUs in 2015. Equipment for emergency surgical airway procedures was available in nearly every ICU (n = 60). The availability of capnography increased significantly from 2010 (n = 12) to 2015 (n = 56; p < 0.0001). In 2010 and 2015, frequent training with a focus on airway management was performed in 23 and 32 units, respectively (p > 0.05). CONCLUSION: Most ICUs in Rhineland-Palatinate have a broad range of equipment for airway management available, and the range has significantly improved over the time period evaluated. The availability of indirect laryngoscopes and capnometers improved significantly. However, it is remarkable that in some ICU's there is still a lack of equipment for advanced airway management.

A comparison of the Enk Fiberoptic Atomizer Set(™) with boluses of topical anaesthesia for awake fibreoptic intubation.

We compared the Enk Fiberoptic Atomizer Set(™) with boluses of topical anaesthesia administered via the working channel during awake fibreoptic tracheal intubation in 96 patients undergoing elective surgery. Patients who received topical anaesthesia via the atomiser, compared with boluses via the fibreoptic scope, reported a better median (IQR [range]) level of comfort: 1 (1-3 [1-10]) vs. 4 (2-6 [1-10]), p < 0.0001; experienced a reduced total number of coughs: 6 (3-10 [0-34]) vs. 11 (6-13 [0-25]), p = 0.0055; and fewer distinct coughing episodes: 7% vs. 27% respectively, p = 0.0133. The atomiser technique was quicker: 5 (3-6 [2-12]) min vs. 6 (5-7 [2-15]) min, p = 0.0009; and required less topical lidocaine: 100 mg (100-100 [80-160]) vs. 200 mg (200-200 [200-200]), p < 0.0001. Four weeks after nasal intubation, the incidence of nasal pain was less in the atomiser group compared with the control group (8% vs. 50%, p = 0.0015). We conclude that the atomiser was superior to bolus application for awake fibreoptic tracheal intubation.

Performance of the C-MAC video laryngoscope in patients after a limited glottic view using Macintosh laryngoscopy.

We applied the C-MAC videolaryngoscope in 52 consecutive patients who were found to have an unexpected Cormack and Lehane grade-3 (n = 49) and grade-4 (n = 3) laryngeal view with the Macintosh laryngoscope. The glottic view improved in 49 (94%) patients using the C-MAC. Tracheal intubation was successful in 49 of 52 patients (94%). In one patient, tracheal intubation failed using the C-MAC despite the presence of a Cormack and Lehane grade-2. These results suggest that the C-MAC videolaryngoscope has a role as a rescue device in cases of an initially difficult laryngeal view.

Evaluation of the novel, single-use, flexible aScope for tracheal intubation in the simulated difficult airway and first clinical experiences.

Flexible fibreoptic intubation is widely accepted as an important modality for the management of patients with difficult airways. We compared the aScope, a novel, single-use, flexible video-endoscope designed to aid tracheal intubation, with a standard flexible intubating fibrescope, by examining the performance of 21 anaesthetists during an easy and difficult intubation simulation in a manikin. Intubation success, time for intubation, and rating of the devices (using a scale from 1, excellent to 6, fail) were documented. Intubation times were similar for both flexible 'scopes in the scenarios (p = 0.59). Successful intubation rates were higher for the standard intubating fibrescope (17/21, 81%) than the aScope (14/21, 67%; p = 0.02) in the difficult intubation scenario. The median (IQR[range]) ratings for the standard fibrescope vs the aScope were respectively: overall, 2 (1.75-2 [1-2.5]) vs 3 (2-3.25 [1-5]) (p < 0.0001); picture quality 2 (1.5-2 [1-3]) vs 3 (2-4 [1-5]) (p < 0.0001). The aScope was also successfully used to facilitate tracheal intubation in five patients with anticipated or unanticipated difficult airways. Picture quality was sufficient to identify the anatomical landmarks. Although the performance of the aScope is acceptable, it does not meet the current quality of standard flexible intubation fibrescopes.

Evaluation of the McGrath Series 5 videolaryngoscope after failed direct laryngoscopy.

SUMMARY: Unanticipated difficulties during tracheal intubation and failure to intubate are among the leading causes of anaesthesia-related morbidity and mortality. Using the technique of video laryngoscopy, the alignment of the oral and pharyngeal axes to facilitate tracheal intubation is unnecessary. In this study we evaluated the McGrath Series 5 videolaryngoscope for tracheal intubation in 61 patients who exhibited Cormack and Lehane grade 3 or 4 laryngoscopies with a Macintosh laryngoscope. Using the McGrath resulted in an improved glottic view, compared to Macintosh laryngoscope. Laryngoscopy was improved by one grade in 10%, by two grades in 80% and by three grades in 10% of cases (p < 0.0001). The success rate for intubation was 95% with the McGrath. These results suggest that the McGrath videolaryngoscope can be used with a high success rate to facilitate tracheal intubation in difficult intubation situations.

[Indirect laryngoscopy : Alternatives to securing the airway]. / Indirekte Laryngoskopie : Alternativen zur Atemwegssicherung.

Endotracheal intubation remains the gold standard for securing the airway in emergency medicine. However, difficult endotracheal intubation and complications are common during emergency intubation. In contrast to conventional direct laryngoscopy, the new generation of devices does not require direct visualization of the vocal cords for endotracheal tube placement. These devices allow a better glottic view and successful endotracheal placement of the tube, especially if direct laryngoscopy is difficult. Recent studies showed that utilization of these devices can be easily learned. The technique of indirect laryngoscopy is currently used for securing the airway in daily anesthesia routine as well as for managing the difficult airway in the operating room. This article gives an overview of available devices for indirect endotracheal intubation as well as the current literature.

[Airway management in a patient with immobilized cervical spine. Preclinical use of the McGrath video-laryngoscope]. / Atemwegssicherung bei immobilisierter Halswirbelsäule. Präklinischer Einsatz des McGrath-Videolaryngoskops.

The McGrath video-laryngoscope was used in a patient with immobilized cervical spine and suspected difficult airway after a high level fall with traumatic brain injury and suspected cervical spine trauma. The airway was successfully secured in the preclinical setting using an oral endotracheal tube with full view of the glottis. Because video-laryngoscopy offers potential advantages compared to established airway management techniques, further studies are required to evaluate the significance of video-laryngoscopy in prehospital emergency medicine.

[Comparison of GlideScope® Cobalt and McGrath® Series 5 video laryngoscopes with direct laryngoscopy in a simulated regurgitation/aspiration scenario]. / Vergleich der Videolaryngoskope GlideScope® Cobalt und McGrath® Series 5 mit konventioneller Laryngoskopie bei simulierter Regurgitation/Aspiration.

BACKGROUND: Video laryngoscopy has become increasingly important in airway management in the pre- and intrahospital settings. However, using video laryngoscopes in the presence of body fluids can make visualization of the airway difficult. A simulated regurgitation model was used to compare two video laryngoscopes (VL) with direct laryngoscopy. MATERIALS AND METHODS: A total of 72 physicians participated in this randomized trial. The hypopharynx from an Airway Management Trainer was filled with artificially warmed turbid liquid. In addition, the cervical spine of the manikin was immobilized. The VL GlideScope® (GS) and McGrath® Series 5 (McG) were examined with the laryngoscope with Macintoshspatel (DL). Fogging of the camera optics in percent (0 %= clear view, 100 %= no view), the visibility of the glottis by Cormack and Lehane classification (C&L), and the POGO Score (percentage of glottic opening), the time until the endotracheal tube placement, and the success rate were evaluated. RESULTS: No fogging (median 0 %) was present using the GS (interquartile range [IQR]: 0-4), in contrast 45 % fogging was found in the McG group (IQR: 30-60; p < 0.001). Glottic visualization using C&L was better using VL (p < 0.001). A similar result was observed using the POGO Scale: GS 90 % (IQR: 76-100), McG 80 % (IQR: 70-90), and DL 20 % (IQR: 0-50). The time for correct placement was in the DL with 27.6 s (IQR: 22.5-35) faster (p < 0.001), with the GS 48.5 s (IQR: 34.3-65.1) and the McG 66.3 s (IQR: 45.4-90). Successful placement was possible with GS in all cases (72/72), with DL in 71/72 cases, and with the McG in 70/72 cases. CONCLUSION: Using a video laryngsocope with an "anti-fogging" system improved visualization in a simulated aspiration model. In this scenario, VL showed no advantage to direct laryngoscopy in terms of success rate and speed of intubation.

[Indirect laryngoscopy/video laryngoscopy. A review of devices used in emergency and intensive care medicine in Germany]. / Indirekte Laryngoskopie/Videolaryngoskopie. Übersicht über in Deutschland verwendete Instrumente in der Notfall- und Intensivmedizin.

Airway management in intensive care or emergency medicine is particularly challenging and is often associated with life-threatening complications. An innovation in the field of airway management is the use of indirect laryngoscopy by means of video laryngoscopes. A digital camera or an optical system at the tip of a laryngoscope blade enables an indirect "look around the corner" to the glottis. Studies have shown that the advantages of video laryngoscopes for endotracheal intubation are particularly beneficial in difficult airway situations. However, the successful use in challenging intubations requires experience and regular use in daily practice. This review gives an overview of indirect laryngoscopes commonly used in Germany and also presents new study results for these novel devices.