Change in management of predicted difficult airways following introduction of video laryngoscopes

AIM To determine if video laryngoscopy(VL) has significantly impacted management of difficult airways by decreasing the rate of awake fiberoptic intubation(FOI). METHODS Anesthetic records of 3723 patients who underwent general anesthesia at Rush University Medical Center were reviewed over a 2-mo period prior to the introduction of VLs in 2009("pre-VL" group) and over the same 2-mo period after the introduction of VLs in 2012("postVL" group). Patient records with predicted difficult air-ways based on pre-operative airway examination were analyzed. The primary outcome was rate of awake FOI.RESULTS To control for possible factors that may influence the FOI rate, a logistic regression was performed with these factors included as covariates. The rate of awake FOI was 13.1% in pre-VL group compared to 9.0% in post-VL group. Although this decrease was not statistically significant individually(P = 0.1768), it showed a trend toward significance when covariates were accounted for(P = 0.0910). Several factors predicting a higherlikelihood of awake FOI were found to be statistically significant: Morbid obesity(larger BMI P = 0.0154, OR = 1.5 per 10 point BMI increase), male gender(P = 0.0026, OR = 3.0) and a higher el-Ganzouri airway score(P = 0.0007, OR = 1.5). Although VLs were seen to be used to intubate 51% of predicted difficult airways, the rate of awake FOI has not significantly changed.CONCLUSION Although VL may continue to grow in popularity, the most difficult airways are still managed using awake FOI.

Climate change and human health: Last call to arms for us

Climate change,now the foremost global health hazard,poses multifaceted challenges to human health.This editorial elucidates the extensive impact of climate change on health,emphasising the increasing burden of diseases and the exacerbation of health disparities.It highlights the critical role of the healthcare sector,particularly anaesthesia,in both contributing to and mitigating climate change.It is a call to action for the medical community to recognise and respond to the health challenges posed by climate change.

全身麻醉经可视麻醉喉镜会厌囊肿切除术

会厌囊肿是耳鼻咽喉科常见疾病,严重者会有窒息危险,明确诊断后应尽早手术切除[1]。我科采用全身麻醉经可视麻醉喉镜会厌囊肿切除术,取得了良好效果。1.1临床资料。2013年4月~2014年3月我科就诊25例会厌囊肿患者,男11例,女14例,年龄27~65岁,平均年龄47.9岁,术前均常规检查排除手术及麻醉禁忌,喉动态镜检查了解会厌囊肿的位置、大小,术前准备完善。1.2方法。患者仰卧位,经鼻或经口气管插管,

显微镜支撑喉镜下改良针状电刀会厌囊肿切除术

会厌囊肿是耳鼻咽喉科常见病、多发病之一,手术切除为其主要治疗方式。我科自2009年6月~2013年12月显微镜支撑喉镜下应用改良针状电刀切除会厌囊肿156例,效果良好,现报道如下。1.1临床资料。患者男81例,女75例;年龄17~67岁,平均34岁;病史6个月~6年。主要症状咽部异物感和吞咽梗阻感。囊肿位于会厌舌面73例,会厌谷39例,舌会厌外侧襞44例。囊肿单发者97例,2个囊肿53例,≥3个6例(其中1例同时并发双侧杓会厌皱襞多发囊肿)。

鼻内镜联合支撑喉镜切除声带良性病变

2009年6月N2011年6月，我科应用鼻内镜联合支撑喉镜行声带良性病变切除术81例，均取得了较好疗效，现报道如下。1资料与方法 1．1一般资料。本组81例患者，男52例，女29例，年龄19～83岁，病程3个月～10年。全部患者均有声音嘶哑、发音困难等症状。其中声带小结9例，声带息肉62例，声带囊肿4例，声带黏膜白斑6例。最大者约4mm×5mm，最小者约2mm×2mm。病变部位为左侧声带41例，右侧声带25例，双侧声带11例，前连合4例。术后均经病理科证实。

Endotracheal intubation in patients with COVID-19 using an ultrathin flexible gastrointestinal endoscope

Pneumonia caused by severe acute respiratory syndrome coronavirus 2 occasionally becomes severe and requires endotracheal intubation.Endotracheal intubation is usually performed using a laryngoscope;however,the operator needs to be in close proximity to the patient’s face during the procedure,which increases the risk of droplet exposure.Therefore,we simulated fiberoptic endotracheal intubation on a mannequin representing the patient,using an ultrathin flexible gastrointestinal endoscope as an alternative to the bronchoscope,in order to maintain distance from the patient during the procedure.We performed this procedure 10 times and measured the time required;the median procedure time was 6.4 s(interquartile range,5.7-8.1 s).The advantage of this method is the short procedure time and distance maintained from the patients.The flexible tip-steerable control and length of the gastrointestinal endoscope contributed to shortening the procedure time and maintaining distance from the patients.In addition,this method can handle difficult airways without risk of misplacement of the endotracheal tube.However,it is necessary to consider the risk of aerosol generation associated with this procedure.In the pandemic setting of coronavirus disease 2019,this approach may be useful when a gastrointestinal endoscopist is in charge of endotracheal intubation of patients with coronavirus disease 2019.

A Comparative Study on the Close Reduction of Arytenoid Dislocation under Indirectand Direct Laryngoscope

To assess the curative effects of different reduction techniques on the dislocation of cricoarytenoid joint caused by intubation,indirect laryngoscope (IL ) and direct laryngoscope (DL ) were utilized for the closed reduction of the displaced arytenoid under local anesthesia.2 3patients who underwent the reduction for dislocated arytenoid under IL or DL from January1991to June 2 0 0 1were reviewed.The data were collected on the duration of the laryngeal injury,tim es of re- ceiving reduction,side- effects after the treatment and the period for voice to return to normal. The relationship between the duration of the laryngeal lesion and the period of the voice rehabilita- tion was examined.13patients received the reduction under IL and 10 patients under DL .Except the tim es of the reduction,which showed significant difference,no differences were found between IL group and DL group in the course and the period of voice rehabilitation,as well as sore throat after the manipulation.The patients'voice recovery was positively related to their course of dis- ease in both IL and DL group.Itis concluded thatthe recovery of normal voice is obviously affect- ed by the duration of arytenoid dislocation.The reduction under IL is as effective as under DL in the treatment of arytenoid dislocation.Reduction by DL is better suit the patients with long tim e course of disease.

Sodium hydroxide-induced esophageal stricture via an endoscopic injection needle: a novel rabbit model of corrosive injury

Purpose: Benign strictures of the esophagus are commonly encountered in clinical practice and are difficult to manage conservatively. This study aimed to establish a novel animal model of benign esophageal stricture by using corrosive-induced injury in rabbits with an injection of sodium hydroxide(NaOH) via a self-made endoscopic injection needle. Materials and Methods: Corrosive injury of the esophagus was induced in 10 rabbits by administration of 1 mL of 1.5% NaOH using a laryngoscope with a self-made endoscopic injection needle. The self-made injection needle was fabricated by modification of the core of an endoscopic injection needle. The laryngoscope examination was performed at 2 weeks and 4 weeks after induction of corrosive injury; esophagography was also performed at 4 weeks to assesse sophageals tricture.A lla nimalsw eree uthanizedat th een dof the fourth week; the esophagus was removed, and stained sectionsw eree xaminedm icroscopically. Results: Laryngoscope examination at 2 weeks showed ulceration. At the end of fo urth we e k,laryngosco py,r a diolo gical, and gross exa m inations showed successful in ductionof e s ophagea l stric turein a llanimal s,without any c omp licatio n.The m eanst r ic t ure inde x at the en dof fourth week wa s49.54±3. 61%; the mean le ngth of stricture w as18.0± 2.5mm.Micros copicexa mina tionrevea ledf ocalulceratio nand subm ucosalth i cke ning secondary to fibrosis. Conclusion:Rab bit esop hageal stri ctu re induced us ing lary ngosc opy with endosco pic injec tion of a sm all am ount of lowcon centration s odium hyd roxid e is a t echn ica lly simp le,safe,and re produ cible meth od for cre atio n of an animal m odel of esophageal stricture.This model can be useful for developing new treatment methods for esop hageal s tricture.

Comparison of postoperative sore throat following laryngoscopy conducted by Miller and Macintosh laryngoscope blades

BACKGROUND: Post operative sore throat (PST) is one of the most common complaints after tracheal intubation. In this study we compared the effects of curved and straight laryngoscope blades on severity and incidence of PST. METHOD: In this prospective randomized clinical trial we evaluated incidence and severity of PST in 147 ASA physical status I–II, aged 18 – 62 y (group Miller, n = 71), (group Macintosh, n = 76) following intubation with Miller and Macintosh laryngoscope blades by using Visual Analog Scale (VAS). RESULTS: The overall incidence of PST in our study was 35.4% (Macintosh group = 39.5% and in Miller group = 31% and P = 0.829). The incidence of PST was not statistically different between two kinds of laryngoscope blades and the mean rank of pain score was not statistically different in recovery room and up to 48 hours after surgery. CONCLUSIONS: Our study showed these types of laryngoscope blade had not association with incidence and severity of PST. .

Use of McGrath^(■) MAC Video Laryngoscope for Nasotracheal Intubation in Patients for Whom Intubation Was Expected to Be Difficult Due to the Limited Mouth Opening

McGrath? MAC video laryngoscope (McG) has been used for orotracheal intubation in both normal patients and patients for whom intubation was expected to be difficult, and has been reported to provide improved visibility of the glottis during tracheal intubation. There are some reports that normal nasotracheal intubation is easier with McG than with macintosh laryngoscope (ML). The usefulness of McG for nasotracheal intubation is beginning to be recognised. We experienced three cases using McG in patients for whom intubation was expected to be difficult due to the limited mouth opening and using McG for those patients enabled smooth nasotracheal intubation. McG provides good visual field during nasotracheal intubation, and is less invasive to the patient.

Optical design and simulation of an integrated OCT and video rigid laryngoscope

An integrated optical coherence tomography(OCT)and video rigid laryngoscope have been designed to acquire surface and subsurface tissue images of larynx simultaneously.The dual-modality system that is based on a common-path design with components as few as possible effec-tively maintains the light transmittance without compromising the imaging quality.In this paper,the field of view(FOV)of the system can reach 70°by use of a gradient index(GRIN)lens as the relay element and a four-lens group as the distal objective,respectively.The simulation showed that the modulation transfer function(MTF)value in each FOV of the rigid video endoscope at 160 lp/mm is greater than 0.1 while the root mean square(RMS)radii of the OCT beam in the center and edge of the FOV are 14.948μm and 73.609μm,respectively.The resolutions of both OCT and video endoscope meet the requirement of clinical application.In addition,all the components of the system are spherical,therefore the system can be of low cost and easy to assemble.

A Comparative Study between Intravenous Fentanyl and Intravenous Lidocaine on Attenuation of Hemodynamic Pressor Responses to Laryngoscopic Intubation: A Prospective Cohort Study, Ethiopia

Introduction: Laryngoscopic intubation is an insertion of endotracheal tube into the trachea for maintenance of airway during general anesthesia. Smooth intubation requires attenuation of pressor responses and maintenance of baseline hemodynamic stability. The primary outcome of this study is to compare intravenous fentanyl and lidocaine as an anesthetics adjuvant on attenuation of hemodynamic pressor responses to Laryngoscopic intubation in elective surgical adult patients. Methods: This prospective cohort study recruits 114 patients who underwent elective surgery under general anesthesia with laryngoscopy and endotracheal tube intubation. The study was conducted from January 1, 2018 to March 30, 2018. Systemic random sampling technique was used to select the study participants. Those patients that received intravenous fentanyl 2 micrograms per kilogram three minutes before intubation as an anesthetics adjuvant are considered as Fentanyl-group (group F). The Lidocaine-group (group L) was those patients who receive 2% intravenous lidocaine 1.5 milligrams per kilogram three minutes before intubation as anesthetics adjuvant. Hemodynamic parameters (heart rate and blood pressure) and other variables were documented starting from 3 minutes before intubation to 5 minutes after intubation. Results: The mean heart rate at first minute after intubation was significantly lower in fentanyl group (98.91 ± 15.6 beats per minute (bpm)) compared to lidocaine (107 ± 15.45 bpm), t (112) = 2.8, p = 0.006. Systolic blood pressure was also significantly lower in fentanyl group (141.9 ± 18.9 millimeters of mercury (mmHg)) compared to lidocaine (150 ± 18.098 mmHg), t (112) = 2.45, p = 0.016 at first minute after intubation. At third minute after intubation, heart rate was significantly lower in fentanyl group compared to lidocaine, t (112), p = 0.037. No difference was in heart rate and blood pressure among the group at 5th minute after intubation (p > 0.05). Conclusion and Recommendations: Fentanyl was better on attenuation of hemodynamic pressor responses to laryngoscopic intubation when compared to lidocaine. Therefore, using fentanyl pre-operatively to attenuate pressor responses especially during intubation is important.

动态喉镜图像主观评估

1878年Oertel发明了动态喉镜，至今100多年来，动态喉镜得到了长足的发展。目前动态喉镜被广泛应用于临床，已经成为喉发音功能检测的常规检查之一。

动态喉镜记波图

动态喉镜是观察发声时声带振动及黏膜波传播的主要检查手段之一，临床应用十分广泛，但对结果的分析主要依靠检查者主观判断进行定性分析，这要求检查者经验十分丰富；同时，由于检查结果缺乏定量指标，难以进行病例间比较和深入分析。为弥补这一不足，人们希望能将动态喉镜检查结果进行客观量化分析。

Shikani Optical Stylet versus Macintosh Laryngoscope for Intubation in Patients Undergoing Surgery for Cervical Spondylosis： A Randomized Controlled Trial

Background： Airway management is critical in patients with cervical spondylosis, a population with a high incidence of difficult airway. Intubation with Shikani Optical Styler （SOS） has become increasingly popular in difficult airway. We compared the effects ofintubation with SOS versus Macintosh laryngoscope （MLS） in patients undergoing surgery for cervical spondylosis. Methods： A total of 270 patients scheduled for elective surgery for cervical spondylosis of spinal cord and nerve root type from August 2012 to January 2016 were enrolled and randomly allocated to the MLS or SOS group by random numbers. Patients were evaluated for difficult airway preoperatively, and Cormack-Lehane laryngoscopy classification was determined during anesthesia induction. Difficult airway was defined as Cormack-Lehane Grades IlI IV. Patients were intubated with the randomly assigned intubation device. The success rate, intubation time, required assistance, immediate complications, and postoperative complaints were recorded. Categorical variables were analyzed by Chi-square test, and continuous variables were analyzed by independent samples t-test or rank sum test. Results： The success rate of intubation among normal airways was 100% in both groups. In patients with difficult airway, the success rates in the MLS and SOS groups were 84.2% and 94.1%, respectively （P = 0.605）. lntubation with SOS took longer compared with MLS （normal airway： 25.1 ± 5.8 s vs. 24.5 ± 5.7 s, P = 0.426; difficult airway： 38.5± 8.5 s vs. 36.1 ±8,2 s, P = 0.389）. Intubation with SOS required less assistance in patients with difficult airway （5.9% vs. 100%, P 〈 0.001 ）. The frequency of postoperative sore throat was lower in SOS group versus MLS group in patients with normal airway （22.0% vs. 34.5%, P =0.034）. Conclusions： SOS is a sale and effective airway management device in patients undergoing surgery for cervical spondylosis. Compared with MLS, SOS appears clinically beneficial for intubation, especially in patients with difficult airway. Trial Registration： Chinese Clinical Trial Registry, ChiCTR-IOR- 16007821 ; http：//www.chictr.org.cn/showproj.aspx？proj-13203.

Current Evidences for the Use of UEscope in Airway Management

Objective：UEscope is a new angulated videolaryngoscope （VL）.This review aimed to describe the features of UEscope and provide clinical evidences regarding the efficacy and safety of this video device in adult tracheal intubation and its roles in airway management teaching.Data Sources：The Wan Fang Data,CNKI,PubMed,Embase,Cochrane Library,and Google Scholar were searched for relevant English and Chinese articles published up to January 15,2017,using the following keywords：＂HC video laryngoscope＂,＂UE videolaryngoscope＂,＂video laryngoscope＂,and ＂videolaryngoscopy＂.Study Selection：Human case reports,case series,observable studies,and randomized controlled clinical trials were included in our search.The results of these studies and their reference lists were cross-referenced to identify a common theme.Results：UEscope features the low-profile portable design,intermediate blade curvatures,all-angle adjustable monitor,effective anti-fog mechanisms,and built-in video recording function.During the past 5 years,there have been a number of clinical studies assessing the application and roles of UEscope in airway management and education.As compared with direct laryngoscope,UEscope improves laryngeal visualization,decreases intubation time （IT）,and increases intubation success rate in adult patients with normal and difficult airways.These findings are somewhat different from the previous results regarding the other angulated VLs;they can provide an improved laryngeal view,but no conclusive benefits with regard to IT and intubation success rate.Furthermore,UEscope has extensively been used for intubation teaching and shown a number of advantages.Conclusions：UEscope can be used as a primary intubation tool and may provide more benefits than other VLs in patients with normal and difficult airways.However,more studies with large sample are still needed to address some open questions about clinical performance of this new VL.

Fibrovascular polyp of the hypopharynx and esophagus

Fibrovascular polyp of the hypopharynx and esophagus, a rare, benign, intraluminal and submucosal tumor, is most commonly originated from the proximal esophagus. We discussed four cases with regurgitation, respiratory symptom or the feeling of a mass in the throat. All the patients were examined with laryngoscope under general anesthesia. A transverse cervical incision was performed in one patient and the polyps were excised under laryngoscope with CO2 laser in the other three patients. All the lesions were removed successfully. Diagnostic and therapeutic principles involved in these cases are presented and discussed. The recognition of fibrovascular polyp of the hypopharynx and esophagus as a potential cause of regurgitation is paramount. Surgical excision is recommended because of the satisfactory outcome.

Circulatory responses to nasotracheal intubation： comparison of GlideScope videolaryngoscope and Macintosh direct laryngoscope

Background The GlideScope videolaryngoscope （GSVL） has been shown to have no special advantage over the Macintosh direct laryngoscope （MDL） in attenuating the circulatory responses to orotracheal intubation, but no study has compared the circulatory responses to nasotracheal intubation （NTI） using the two devices. This prospective randomized clinical study was designed to determine whether there was a clinically relevant difference between the circulatory responses to NTI with the GSVL and the MDL. Methods Seventy-six adult patients were randomly allocated equally to the GSVL group and the MDL group. After induction of anesthesia, NTI was performed. Non-invasive blood pressure （BP） and heart rate （HR） were recorded before induction （baseline values） and immediately before intubation （post-induction values）, at intubation and every minute for a further five minutes. During the observation, times required to reach the maximum values of systolic BP （SBP） and HR, times required for recovery of SBP and HR to postinduction values and incidence of SBP and HR percent changes 〉 30% of baseline values were also noted. The product of HR and systolic BP, i.e. rate pressure product （RPP）, and the areas under SBP and HR vs. time curves （AUGsBP and AUGHR） were calculated. Results The NTI with the GSVL resulted in significant increases in BP, HR and RPP compared to postinduction values, but these circulatory changes did not exceed baseline values. BPs at all measuring points, AUGSBP, maximum values of BP and incidence of SBP percent increase 〉 30% of baseline value during the observation did not differ significantly between groups. However, HR and RPP at intubation and their maximum values, AUGHR and incidence of HR percent increase 〉 30% of baseline value were significantly higher in the MDL group than in the GSVL group. Times required for recovery of SBP and HR to postinduction values were significantly longer in the MDL group than in the GSVL group. Conclusions The pressor response to NTI with the GSVL and the MDL was similar, but the tachycardiac response to NTI was lesser and of a shorter duration when using a GSVL than when using an MDL.

Improving pediatric resident laryngoscopy training through the use of a video laryngoscope

Importance:Opportunities for pediatric residents to perform direct laryngoscopy and tracheal intubation(DLTI)are few and the success rate is low.Objective:We hypothesize that incorporation of video laryngoscope(McGrath MAC)into pediatric residents DLTI simulation course will improve the simulated DLTI success rate.Methods:Residents were given 3 attempts at DLTI:(1)baseline using a conventional laryngoscope(CL);(2)using a video laryngoscope(VL);and(3)again using the CL.Residents were given up to 120 seconds to complete each DLTI attempt.Time to successful DLTI was collected.Residents recorded their best view(larynx,epiglottis,vocal cords)with each DLTI attempt.Results:Prior to the intervention,15/17(88.2%)and 16/17(94.1%)of the participants reported prior exposure to DLTI as'less than 10 total attempts'in simulated and live patients respectively.Seventeen pediatric residents performed 51 DLTI attempts(34 with a CL and 17 with the VL).Success rates for DLTI are as follows:Baseline with CL 11/17(64.7%),VL 12/17(70.6%),and last attempt with CL 13/17(76.5%)(P=0.15).Compared to the baseline,the use of VL resulted in a shorter but non-significant decrease in time to successful DLTI(Mean 34.2 sec[SD,22.0]vs.56.5 sec[SD,40.2];P=0.08).Repeat attempts at DLTI with the CL,however,were significantly shorter than baseline(Mean 20.3 sec[SD,12.8]vs.56.5 sec[SD,40.2];P=0.003).Using the VL,more residents could visualize the vocal cords compared to the baseline(14/17[82.3%]vs.9/17[52.9%];P=0.03).Interpretation:Repeated training is certainly a way to improve successful DLTI.Use of VL as a new teaching method led to greater visualization of the vocal cords,shortening operating time and raising self-confidence.

Severe airway obstruction caused by tonsillar polyp in anesthetized patient

The tonsillar polyp is a rare benign tumor of the pharynx.1 We describe a successful management of a case with severe airway obstruction by the tonsillar polyp after anesthesia induction in an adult patient with a known difficult airway.In this case,airway was successfully rescued with a difficult airway management scheme incorporating a videolaryngoscope.