Search

Purpose: Our study aimed to provide consensus and expert clinical practice statements related to airway management in critically ill adults with a physiologically difficult airway (PDA)., Methods: An international Steering Committee involving seven intensivists and one Delphi methodology expert was convened by the Society of Critical Care Anaesthesiologists (SOCCA) Physiologically Difficult Airway Task Force. The committee selected an international panel of 35 expert clinician-researchers with expertise in airway management in critically ill adults. A Delphi process based on an iterative approach was used to obtain the final consensus statements., Results: The Delphi process included seven survey rounds. A stable consensus was achieved for 53 (87%) out of 61 statements. The experts agreed that in addition to pathophysiological conditions, physiological alterations associated with pregnancy and obesity also constitute a physiologically difficult airway. They suggested having an intubation team consisting of at least three healthcare providers including two airway operators, implementing an appropriately designed checklist, and optimizing hemodynamics prior to tracheal intubation. Similarly, the experts agreed on the head elevated laryngoscopic position, routine use of videolaryngoscopy during the first attempt, preoxygenation with non-invasive ventilation, careful mask ventilation during the apneic phase, and attention to cardiorespiratory status for post-intubation care., Conclusion: Using a Delphi method, agreement among a panel of international experts was reached for 53 statements providing guidance to clinicians worldwide on safe tracheal intubation practices in patients with a physiologically difficult airway to help improve patient outcomes. Well-designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties., (© 2024. Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: Evidence-based practice and precision medicine can significantly benefit from the ability to perform calibrated spatial measurements (eg, mm) from endoscopic images. However, calibrated measurements are not readily available from laryngeal images. Laser-projection endoscopes can provide the required information for performing calibrated spatial measurements, but their applications require a process known as calibration. During calibration, a set of benchtop recordings are used to determine the effect of confounding factors of spatial measurements, and also to learn their proper compensation strategies. Calibration benchtop recordings are acquired from flat surfaces and at a perpendicular imaging angle which is significantly different from in-vivo situations, where a three-dimensional (3D) surface gets recorded at a semi-unknown imaging angle. The aim of this study was to quantify changes in calibrated vertical and horizontal measurement accuracies as we move from the controlled condition of calibration to more realistic and uncontrolled settings., Method: A flat surface was positioned in front of a calibrated laser-projection transnasal fiberoptic endoscope at different working distances and imaging angles. Calibrated vertical and horizontal measurement errors were computed from each condition. Multiple linear regression analyses were used to quantify the dependence of vertical and horizontal measurement errors on the imaging angle and working distance. Next, a 3D-printed surface was positioned in front of the laser-projection endoscope at different working distances. Calibrated vertical and horizontal measurement errors were computed from each condition and then they were compared to measurement errors from a flat surface positioned at comparable working distances., Results: The outcome of analyses supported a significant effect of imaging angle on calibrated vertical measurement accuracy, while no significant effect of imaging angle on calibrated horizontal measurement accuracy was established. Additionally, the result of multiple linear regression analyses showed that the coefficient of imaging angle was two times larger than the working distance, which further highlights the significant effect of imaging angle on vertical measurement accuracy. Comparing the magnitude of calibrated vertical and horizontal measurement errors between the 3D surface and a flat surface suggested a significant effect of surface topology on calibrated measurement accuracies., Conclusions: The mean percent magnitude of error of vertical and horizontal measurement errors from the 3D surface were respectively around 6% and 11%, at most working distances, which are acceptable for many applications. However, the significant effect of imaging angle and surface topology on measurement errors highlights the need for further research on these confounding factors. It also suggests that significant improvements in measurement accuracies may be achieved if these factors are properly accounted for during the calibration process. Last but not least, this study highlights the need for the evaluation of laser-projection endoscopes in uncontrolled and more realistic settings. Specifically, evaluations of laser-projection endoscopes in very controlled settings could significantly overestimate their accuracies and hence it will not represent their actual performances during in-vivo data acquisitions., (Copyright © 2021 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

The German guidelines for airway management aim to optimize the care of patients undergoing anesthesia or intensive care. The preanesthesia evaluation is an important component for detection of anatomical and physiological indications for difficult mask ventilation and intubation. If predictors for a difficult or impossible mask ventilation and/or endotracheal intubation are present the airway should be secured while maintaining spontaneous breathing. In an unexpectedly difficult intubation, attempts to secure the airway should be limited to two with each method used. A video laryngoscope is recommended after an unsuccessful direct laryngoscopy. Therefore, a video laryngoscope should be available at every anesthesiology workspace throughout the hospital. Securing the airway should primarily be performed with a video laryngoscope in critically ill patients and patients at risk of pulmonary aspiration. Experienced personnel should perform or supervise airway management in the intensive care unit., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Objective: Calibrated horizontal-plane measurements from laryngeal images could contribute significantly to refining evidence-based practice and developing patient-specific models and precision-medicine approaches. Laser-projection endoscopes can address the need for direct calibrated measures; however, these systems are not widely available. This study presents the framework for an alternative indirect horizontal-plane calibration approach., Method: A spatial attribute of a common object, a distinct characteristic that is maintained across images, may be used as a scale for the normalization of other spatial measurements. The outcome of this indirect approach could be used for absolute measurements (eg, in units of mm) or relative measurements (eg, percent change), depending on the information that is available from the common attribute. The required conditions of a common attribute for achieving a valid calibration outcome were studied. Three conditions were derived: registration accuracy of the common attribute, size consistency of the common attribute, and similarity in the vertical distance between the region of interest (ROI) (eg, vocal fold) and the common attribute. Any common attribute satisfying these three conditions was called proper and would result in a valid indirect calibration outcome. Three tests were presented for evaluating the properness of a common attribute. A data-driven statistical method was presented that can evaluate the registration accuracy of a common attribute. The second test used variation in calibrated lengths of a common attribute under different phonatory configurations for evaluating the size consistency condition. Finally, the effect of differences between vertical distances of the ROI and the common attribute was mathematically tested and quantified. The application of the proposed framework for indirect calibration was demonstrated using a pre existing dataset with a vocal fold as the ROI and four different common attributes (vocal fold length, vocal fold width, blood vessel on the vocal fold, and blood vessel on nearby tissue)., Results: The proposed registration-accuracy test was able to detect and eliminate instances of common attributes with low accuracies. The analysis suggested that among the studied four common attributes, the vocal fold length had the highest (ie, best) registration accuracy; however, the vocal fold length exhibited the lowest (ie, worst) size consistency. The analysis also suggested that, among the studied attributes, the vocal fold width offered the best trade-off among the three conditions and, hence, was a proper common attribute for calibrating spatial aspects of the vocal folds (length, displacement of edges, velocity, etc)., Conclusion: Indirect calibration is a feasible alternative for calibration of laryngeal endoscopic images, given a proper common attribute is selected. Future work is needed to systematically evaluate the effects of various phonatory conditions on the characteristics of common attributes., Competing Interests: Conflict of interest Drs. Robert Hillman and Daryush Mehta have a financial interest in InnoVoyce LLC, a company focused on developing and commercializing technologies for the prevention, diagnosis, and treatment of voice-related disorders. Dr. Hillman's and Dr. Mehta's interests were reviewed and are managed by Massachusetts General Hospital and Mass General Brigham in accordance with their conflict-of-interest policies., (Copyright © 2021 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Videolaryngoscopes are thought to improve glottic view and facilitate tracheal intubation compared with the Macintosh direct laryngoscope. However, we currently do not know which one would be the best choice in most patients undergoing anaesthesia. We designed this systematic review with network meta-analyses to rank the different videolaryngoscopes and the Macintosh direct laryngoscope. We conducted searches in PubMed and a further five databases on 11 January 2021. We included randomised clinical trials with patients aged ≥16 years, comparing different videolaryngoscopes, or videolaryngoscopes with the Macintosh direct laryngoscope for the outcomes: failed intubation; failed first intubation attempt; failed intubation within two attempts; difficult intubation; percentage of glottic opening seen; difficult laryngoscopy; and time needed for intubation. We assessed the quality of evidence according to GRADE recommendations and included 179 studies in the meta-analyses. The C-MAC and C-MAC D-Blade were top ranked for avoiding failed intubation, but we did not find statistically significant differences between any two distinct videolaryngoscopes for this outcome. Further, the C-MAC D-Blade performed significantly better than the C-MAC Macintosh blade for difficult laryngoscopy. We found statistically significant differences between the laryngoscopes for time to intubation, but these differences were not considered clinically relevant. The evidence was judged as of low or very low quality overall. In conclusion, different videolaryngoscopes have differential intubation performance and some may be currently preferred among the available devices. Furthermore, videolaryngoscopes and the Macintosh direct laryngoscope may be considered clinically equivalent for the time taken for tracheal intubation. However, despite the rankings from our analyses, the current available evidence is not sufficient to ensure significant superiority of one device or a small set of them over the others for our intubation-related outcomes., (© 2021 Association of Anaesthetists.)

Background: Small plateau (SP) on the flow-volume curve was found in parts of patients with suspected asthma or upper airway abnormalities, but it lacks clear scientific proof. Therefore, we aimed to characterize its clinical features., Methods: We involved patients by reviewing the bronchoprovocation test (BPT) and bronchodilator test (BDT) completed between October 2017 and October 2020 to assess the characteristics of the sign. Patients who underwent laryngoscopy were assigned to perform spirometry to analyze the relationship of the sign and upper airway abnormalities. SP-Network was developed to recognition of the sign using flow-volume curves., Results: Of 13,661 BPTs and 8,168 BDTs completed, we labeled 2,123 (15.5%) and 219 (2.7%) patients with the sign, respectively. Among them, there were 1,782 (83.9%) with the negative-BPT and 194 (88.6%) with the negative-BDT. Patients with SP sign had higher median FVC and FEV 1 % predicted (both P < .0001). Of 48 patients (16 with and 32 without the sign) who performed laryngoscopy and spirometry, the rate of laryngoscopy-diagnosis upper airway abnormalities in patients with the sign (63%) was higher than those without the sign (31%) (P = 0.038). SP-Network achieved an accuracy of 95.2% in the task of automatic recognition of the sign., Conclusions: SP sign is featured on the flow-volume curve and recognized by the SP-Network model. Patients with the sign are less likely to have airway hyperresponsiveness, automatic visualizing of this sign is helpful for primary care centers where BPT cannot available., (© 2021. The Author(s).)

Our objective was to compare video-assisted laryngoscopy (VAL) with direct laryngoscopy (DL) for glottic visualization in a pediatric intensive care unit in terms of the success rate in first attempts. Our study included patients aged from 1 month to 18 years who were admitted to the pediatric intensive care unit. We excluded patients with limited neck extension (C-spine immobilization, congenital abnormality), congenital anomalies (e.g., Pierre Robin syndrome, micrognathia, macroglossia), and recent airway surgery. Patients were premedicated before intubation. The time to intubation was defined as the time between the start of anesthesia and completion of intubation. The start of anesthetic induction was defined as the time the sedative was first administered. Completion of intubation was defined as the time that the end-tidal carbon dioxide tension was detected. We evaluated 120 of 135 intubations that met our inclusion criteria; 15 were excluded because in eight cases (53%) non-pediatric intensive care physicians made the initial attempts, and in seven cases (47%) the recorded intubation times were erroneous. We detected significantly higher POGO scores in the VAL group (p<0.001). VAL provided a fuller view of the glottis (Cormack and Lehane grade 1) than DL (p<0.001). Although the intubation attempts in the DL group were significantly higher (two or more attempts), no intubation failures occurred in either group., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest No financial relationship., (Copyright © 2021 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.)

Objectives/hypothesis: Laryngeal electromyography (LEMG) is a diagnostic tool for patients with suspected neurogenic abnormalities of the larynx. LEMG is often used with the assumption that any abnormality is symptom-/disease-related. We sought to determine the prevalence of abnormal LEMG findings in a group of healthy asymptomatic adults across a large age spectrum., Study Design: Open, prospective study, gender-match and age balanced by decade., Methods: Forty-six healthy participants (age 20-78) underwent LEMG, including 178 muscles. Participants had no history of voice problems, normal VHI-10, and normal flexible laryngoscopy. Qualitative and quantitative LEMG (bilateral) were performed involving the thyroarytenoid-lateral cricoarytenoid muscle complex (TA-LCA) and cricothyroid (CT) muscles. LEMG parameters included evaluation for fibrillation potentials, sharp waves, reduced recruitment, polyphasic potentials, electrical synkinesis, and measurement of turns per second., Results: Of participants, 4% had at least one abnormal qualitative finding (slightly reduced recruitment or two to three discrete polyphasic potentials). There were no findings of fibrillation potentials or sharp waves. There were no abnormal qualitative findings in the CT muscles tested. Of participants, 16% had at least one abnormal synkinesis finding. LEMG qualitative abnormalities and quantitative abnormalities do not appear to correlate with gender or age., Conclusion: Abnormal qualitative and quantitative LEMG findings were uncommon and minor in severity in our group of asymptomatic healthy adults. The likelihood of abnormal LEMG results in asymptomatic adults was 2.2% for qualitative findings, 9.3% for synkinesis, and 5.4% for turns/s., Level of Evidence: 3 Laryngoscope, 131:2065-2069, 2021., (© 2021 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Introduction: Advanced airway management is necessary in the prehospital environment and difficult airways occur more commonly in this setting. Failed intubation is closely associated with the most devastating complications of airway management. In an attempt to improve the safety and success of tracheal intubation, we implemented videolaryngoscopy (VL) as our first-line device for tracheal intubation within a UK prehospital emergency medicine (PHEM) setting., Methods: An East of England physician-paramedic PHEM team adopted VL as first line for undertaking all prehospital advanced airway management. The study period was 2016-2020. Statistical process control charts were used to assess whether use of VL altered first-pass intubation success, frequency of intubation-related hypoxia and laryngeal inlet views. A survey was used to collect the team's views of VL introduction., Results: 919 patients underwent advanced airway management during the study period. The introduction of VL did not improve first-pass intubation success, view of laryngeal inlet or intubation-associated hypoxia. VL improved situational awareness and opportunities for training but performed poorly in some environments., Conclusion: Despite the lack of objective improvement in care, subjective improvements meant that overall PHEM clinicians wanted to retain VL within their practice., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: This study aimed to report the pre- and post-operative laryngeal endoscopic findings in patients referred by non-otolaryngologists who are undergoing thyroid and/or parathyroid surgery, and to determine the number and nature of referrals before and after the release of the clinical practice guideline for improving voice outcomes after thyroid surgery., Methods: This retrospective cohort study, conducted at a tertiary care academic hospital, comprised adult patients referred by the endocrine surgery service for laryngoscopy from 2007 to 2018 (n = 166). Data regarding patient demographics, reason for referral and endoscopic findings were recorded., Results: The number of referrals increased significantly after the release of the practice guideline. The most common indication for referral pre- and post-operatively was voice change. The most common finding during laryngoscopy was normal examination findings (pre-operatively) and unilateral vocal fold immobility (post-operatively)., Conclusion: Peri-operative thyroid and/or parathyroid patients have laryngoscopic findings other than vocal fold immobility. Laryngoscopy to detect structural and functional pathology is warranted.

Background: "Macintosh"-videolaryngoscopes (VLs) are VLs that allow both direct and indirect laryngoscopy for intubation. We describe the decision-making and implementation-processes that our hospital used regarding the choice of device. We compared the performances of 4 Macintosh-VLs both in direct and indirect laryngoscopy., Methods: A quality-improvement-project for airway management aiming at implementing Macintosh-VL for all intubation procedures performed in the operating room, involving 4 Macintosh-VLs (McGrath-Mac, C-MAC-S, C-MAC-S-Pocket-Monitor [PM], and APA). Three consecutive steps were described: (1) direct laryngoscopy with Macintosh-VL, (2) indirect laryngoscopy with Macintosh-VL (intubation attempt with Macintosh-style blade in case of Cormack I or II), (3) intubation attempt with hyperangulated blade in case of Cormack III/IV or failure of Macintosh-style blade. The main end point was the need to move to step III and use a hyperangulated blade. A mixed-effects multivariable logistic regression analysis was performed to compare devices on the main end point while considering site as a random effect. Comparison of means was performed using analysis of variance and Tukey's test for multiple comparisons (number of laryngoscopy attempts, numeric rate scale [NRS] difficulty of intubation and NRS user-friendliness). Comparison of percentages was performed using a χ2 test for the need to move to step III and a Kruskal-Wallis test for the quality of image (bad, passable, good, very good, excellent). A P value ≤.008 was considered statistically significant., Results: From May to September 2017, 589 patients were included. Using the McGrath-Mac (22/180 [12%]) was associated with less use of hyperangulated blade than using the C-MAC-S (39/132 [30%], odds ratio [OR] [99.2% confidence interval {CI}] 0.34 [0.16-0.77], P = .0005), the APA (35/138 [25%], OR [99.2% CI] 0.42 [0.19-0.93]; P = .004), but not the C-MAC-S-PM (29/139 [21%], OR [99.2% CI] 0.53 [0.23-1.2]; P = .04).Overall, the number of intubation attempts was significantly lower using the McGrath Mac than the C-MAC-S or the C-MAC-S-PMVLs. Subjective appreciation of intubation difficulty and user-friendliness of the devices showed respectively lower and higher NRS scores for the McGrath-Mac compared to the other devices, whereas subjective assessment of image quality showed higher quality for the C-MAC-S and C-MAC-S-PM compared to the APA or McGrath-Mac., Conclusions: Among 4 single-use Macintosh-VLs, glottic visualization in direct and indirect laryngoscopy with the Macintosh-style blade was significantly improved with the McGrath-Mac compared to other Macintosh-VLs, leading to a less frequent need to resort to the hyperangulated blade and reduced overall number of intubation attempts., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2020 International Anesthesia Research Society.)

Background: Fibre-optic nasoendoscopy and fibre-optic laryngoscopy are high-risk procedures in the coronavirus disease 2019 era, as they are potential aerosol-generating procedures. Barrier protection remains key to preventing transmission., Methods: A device was developed that patients can wear to reduce potential aerosol contamination of the surroundings., Conclusion: This device is simple, reproducible, easy to use, economical and well-tolerated. Full personal protection equipment should additionally be worn by the operator.

Introduction: To determine the consistency and accuracy of preoperative diagnosis in the voice clinic with intraoperative diagnosis and to suggest a standardized laryngeal examination protocol in the UK that is supported by evidence-based findings., Method: From January 2011-September 2014, 164 patients were referred to the Multidisciplinary Team voice clinic and diagnosed with laryngeal pathology that required phonosurgery. The visualization (videostrobolaryngoscopy) in clinic was performed using either rigid laryngoscope or a video-naso-laryngoscope. Intraoperatively, laryngeal visualization and surgical procedure was conducted using Storz Aida HD system, 10-mm rigid laryngoscope 0° or 5-mm rigid laryngoscope 0°/30° and a Zeiss S7 microscope., Results: Of the 164 patients seen in the multidisciplinary voice clinic, 86 clinic diagnoses were confirmed intraoperatively (52.4%), 15 patients had the diagnosis confirmed intraoperatively with additional lesion found (9.1%). The clinic diagnosis changed intraoperatively in 63 cases (38.4%). 61 (37.2%) patients seen in the voice clinic were diagnosed with cyst, in 39.3% the diagnosis was confirmed intraoperatively with 5 cases (8.2%) having an additional diagnosis. Twenty (12.2%) patients were diagnosed with polyps, with 80% confirmation intraoperatively; 3 patients (10%) had an additional diagnosis., Conclusion: Videolaryngostroboscopy imaging of the larynx provides an outpatient tool for accurately diagnosing more than 50% of laryngeal pathologies when interpreted by multidisciplinary voice clinicians. However direct laryngeal examination under general anesthesia remains the gold standard when obtaining accurate diagnoses of laryngeal pathology. Patients diagnosed with nonorganic voice disorders should be considered for direct laryngoscopy under general anesthetic should they fail to respond to conservative management., (Copyright © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

As a single and reliable parameter for prediction of the difficult airway is missing, the specialist societies for anesthesiology recommend the use of scores that combine the individual parameters. Contemporary scores include head-neck mobility, mouth opening and anatomical distances. Their training and correct performance are essential. For a broad acceptance the performance has to be easy and fast. In addition, before anesthesia a check must be made for pathological alterations (e.g. tumors) in the head and neck region and the patient history must be thoroughly determined. If the patient reports difficulties with securing the airway in the past, these are likely to occur again if they have not been surgically resolved. This includes an accurate documentation of the airway and knowledge of the in-house standard operating procedure on unexpected difficult airways as well as local equipment. Preparation causes work but may save lives.

Diagnostic flexible laryngoscopy (DFL) is a critical tool in the armamentarium of an otolaryngologist. However, in the midst of the COVID-19 pandemic, DFL represents a high-risk procedure for patients and otolaryngologists due to the risk of aerosolization. In cases where DFL is required, in patients with COVID-19 positivity or unknown COVID-19 status, we describe the use of a modified endoscopy face mask as an adjunct to personal protection equipment to reduce occupational transmission of COVID-19 while performing DFL. Our modified endoscopy mask provides an additional barrier against the transmission of airborne pathogens. The modified endoscopy face mask may also serve as a useful tool for otolaryngologists as they return to performing more aerosol-generating procedures in the outpatient setting.

Background: Approximately half of all difficult tracheal intubations (DTIs) are unanticipated; hence, proper positioning during intubation is critical to increase the likelihood of success. The bed-up-head-elevated (BUHE) intubation position has been shown to improve laryngeal view, reduce airway complications, and prolong safe apneic time during intubation. In this study, we sought to determine whether the BUHE intubation position is noninferior to Glidescope (GLSC)-assisted intubation with regard to laryngeal exposure., Methods: A total of 138 American Society of Anesthesiologists (ASA) I to III patients were randomly assigned into 2 groups and underwent baseline laryngoscopy in the sniffing position. Group BUHE patients (n = 69) were then intubated in the BUHE position, while group GLSC patients (n = 69) were intubated using GLSC laryngoscopy. Laryngeal exposure was measured using Percentage of Glottic Opening (POGO) score and Cormack-Lehane (CL) grading, and noninferiority will be declared if the difference in mean POGO scores between both groups do not exceed -15% at the lower limit of a 98% confidence interval (CI). Secondary outcomes measured included time required for intubation (TRI), number of intubation attempts, use of airway adjuncts, effort during laryngoscopy, and complications during intubation., Results: Mean POGO score in group BUHE was 80.14% ± 22.03%, while in group GLSC it was 86.45% ± 18.83%, with a mean difference of -6.3% (98% CI, -13.2% to 0.6%). In both groups, there was a significant improvement in mean POGO scores when compared to baseline laryngoscopy in the sniffing position (group BUHE, 25.8% ± 4.7%; group GLSC, 30.7% ± 6.8%) (P < .0001). The mean TRI was 36.23 ± 14.41 seconds in group BUHE, while group GLSC had a mean TRI of 44.33 ± 11.53 seconds (P < .0001). In patients with baseline CL 3 grading, there was no significant difference between mean POGO scores in both groups (group BUHE, 49.2% ± 19.6% versus group GLSC, 70.5% ± 29.7%; P = .054)., Conclusions: In the general population, BUHE intubation position provides a noninferior laryngeal view to GLSC intubation. The laryngeal views obtained in both approaches were superior to the laryngeal view obtained in the sniffing position. In view of the many advantages of the BUHE position for intubation, the lack of proven adverse effects, the simplicity, and the cost-effectiveness, we propose that clinicians should consider the BUHE position as the standard intubation position for the general population.

A short-cut review of the literature was carried out to examine whether video laryngoscopy (VL) could improve first-pass success and reduce complication rates in ED patients requiring endotracheal intubation, when compared with direct laryngoscopy. Four papers were identified as suitable for inclusion using the reported search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated. It is concluded that current evidence suggests VL is likely to improve first-pass success and reduce oesophageal intubation rates, but there is no evidence at present that it improves clinically relevant outcomes. In addition, no difference was found between first-pass success rates in senior/experienced operators, who should use techniques with which they are familiar., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: 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., Methods: 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., Results: 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)., Conclusions: 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.

Objectives: Critically ill patients are often transferred from the intensive care unit (ICU) to other locations around the hospital during which adverse events, some life threatening, are common. An intercollegiate guideline covering the transport of critically ill patients exists in Australasia; however, compliance with this guideline has previously been shown to be poor, and its role in improving safety in transportation of patients in the ICU is unknown. We performed a pre-post interventional study in a tertiary metropolitan ICU, assessing the impact of the introduction of a transport checklist on guideline compliance., Methods: We performed a prospective, pre-post interventional study, including a total of 76 transfers of critically ill patients between August 2016 and April 2017., Results: After introduction of the checklist, aggregate median (interquartile range) guideline compliance improved from 86.7% (80.0-92.9) to 90% (86.7-100) (p = 0.01). Significant improvements were found in notification of the transport destination (83.7% vs 100%, p = 0.010) and transporting doctors' knowledge of the Cormack-Lehane grade of laryngoscopy (60.5% vs. 84.2%, p = 0.021). There was, however, a reduction in the proportion of full oxygen cylinders taken on transports (100% vs. 76.3%, p = 0.002)., Conclusions: We conclude that a checklist is useful in improving safety in the transport of a critically ill patient population., (Copyright © 2019. Published by Elsevier Ltd.)

Despite its value in emergency airway management, the endotracheal tube introducer, commonly known as the bougie, has traditionally been a point of disagreement between providers. It is typically viewed as a "rescue" device and not a primary airway tool. However, its value as a primary device during plan A has recently been recognized. Two studies have shown increased first-pass success using a bougie on the initial attempt. Additionally, bougie use on every intubation increases provider comfort with the device so that, on a truly difficult intubation, the skills and mechanics are instilled. In the out-of-hospital and critical care transport settings, intubation is often inherently more difficult because of varying environments. For these reasons, the bougie should be integrated into the first intubation attempt in emergent intubation., (Copyright © 2019 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Background: In patients with an unstable cervical spine, maintenance of cervical immobilization during tracheal intubation is important. In McGrath videolaryngoscopic intubation, lifting of the blade to raise the epiglottis is needed to visualize the glottis, but in patients with an unstable cervical spine, this can cause cervical spine movement. By contrast, the Optiscope, a rigid video-stylet, does not require raising of the epiglottis during tracheal intubation. We therefore hypothesized that the Optiscope would produce less cervical spine movement than the McGrath videolaryngoscope during tracheal intubation. The aim of this study was to compare the Optiscope with the McGrath videolaryngoscope with respect to cervical spine motion during intubation in patients with simulated cervical immobilization., Methods: The primary outcome of the study was the extent of cervical spine motion at the occiput-C1, C1-C2, and C2-C5 segments. In this randomized crossover study, the cervical spine angle was measured before and during tracheal intubation using either the Optiscope or the McGrath videolaryngoscope in 21 patients with simulated cervical immobilization. Cervical spine motion was defined as the change in angle at each cervical segment during tracheal intubation., Results: There was significantly less cervical spine motion at the occiput-C1 segment using the Optiscope rather than the McGrath videolaryngoscope (mean [98.33% CI]: 4.7° [2.4-7.0] vs 10.4° [8.1-12.7]; mean difference [98.33% CI]: -5.7° [-7.5 to -3.9]). There were also fewer cervical spinal motions at the C1-C2 and C2-C5 segments using the Optiscope (mean difference versus the McGrath videolaryngoscope [98.33% CI]: -2.4° [-3.7 to -1.2]) and -3.7° [-5.9 to -1.4], respectively)., Conclusions: The Optiscope produces less cervical spine motion than the McGrath videolaryngoscope during tracheal intubation of patients with simulated cervical immobilization.

Background: The video laryngoscope is recommended for intubating difficult airways. The present study aimed to determine whether the video laryngoscope can further improve intubation success rates compared with the direct laryngoscope in patients with non-difficult airways., Methods: In total, 360 patients scheduled for elective abdominal surgeries were randomly assigned to undergo intubation using either a video laryngoscope (n = 179) or a direct laryngoscope (n = 181). The following parameters were measured: mouth opening; thyromental distance; sternomental distance; shape angle of the tracheal catheter; and glottic exposure grade., Results: The percentage of patients with level I-II of total glottic exposure in the video laryngoscope group was 100% versus 63.5% in the direct laryngoscope group (P < 0.001). The one-attempt success rate of intubation was 96.1% using a video laryngoscope versus 90.1% using a direct laryngoscope (P = 0.024). The intubation success rate using a video laryngoscope was 100% versus 94.5% using a direct laryngoscope (P = 0.004). Immediate oropharyngeal injury occurred in 5.1% of patients intubated using a direct laryngoscope versus 1.1% using a video laryngoscope (P = 0.033). On postoperative day 1, obvious hoarseness was exhibited by 7.9% of patients intubated using a direct laryngoscope versus 2.8% using a video laryngoscope (P = 0.035). The grade of glottic exposure and catheter shape angle were independent risk factors for tracheal intubation failure. Thyromental distance, shape angle, glottic exposure time, and surgical position were independent risk factors for postoperative complications. Thyromental distance and glottic exposure time were independent risk factors for complications lasting > 2 days., Conclusions: Intubation using a video laryngoscope yielded significantly higher intubation success rates and significantly fewer postoperative complications than direct laryngoscopy in patients with non-difficult airways., Trial Registration: Chinese Clinical Trial Registry. No: ChiCTR-IOR-16009023 . Prospective registration.

Background: Airway management is crucial and, probably, even the most important key competence in anaesthesiology, which directly influences patient safety and outcome. However, high-quality research is rarely published and studies usually have different primary or secondary endpoints which impedes clear unbiased comparisons between studies. The aim of the present study was to gather and analyse primary and secondary endpoints in video laryngoscopy studies being published over the last ten years and to create a core set of uniform or homogeneous outcomes (COS)., Methods: Retrospective analysis. Data were identified by using MEDLINE® database and the terms "video laryngoscopy" and "video laryngoscope" limited to the years 2007 to 2017. A total of 3351 studies were identified by the applied search strategy in PubMed. Papers were screened by two anaesthesiologists independently to identify study endpoints. The DELPHI method was used for consensus finding., Results: In the 372 studies analysed and included, 49 different outcome categories/columns were reported. The items "time to intubation" (65.86%), "laryngeal view grade" (44.89%), "successful intubation rate" (36.56%), "number of intubation attempts" (23.39%), "complications" (21.24%), and "successful first-pass intubation rate" (19.09%) were reported most frequently. A total of 19 specific parameters is recommended., Conclusions: In recent video laryngoscopy studies, many different and inhomogeneous parameters were used as outcome descriptors/endpoints. Based on these findings, we recommend that 19 specific parameters (e.g., "time to intubation" (inserting the laryngoscope to first ventilation), "laryngeal view grade" (C&L and POGO), "successful intubation rate", etc.) should be used in coming research to facilitate future comparisons of video laryngoscopy studies.

Background: In patients with predictive features associated with easy direct laryngoscopy, videolaryngoscoy with the GlideScope has been shown to require less force when compared with Macintosh direct laryngoscopy., Objective: The aim of this study was to compare forces applied with Glidescope vs. Macintosh laryngoscopes in patients with predictive features associated with difficult direct laryngoscopy., Design: A randomised study., Setting: Toronto General Hospital, a university tertiary centre in Canada., Patients: Forty-four patients aged over 18 years, with one or more features of difficult intubation, undergoing elective surgery requiring single-lumen tracheal intubation., Intervention: We measured the force applied to oropharyngeal tissues by attaching three FlexiForce Sensors (A201-25) to the concave surface of Macintosh and GlideScope laryngoscope blades.Anaesthetists or experienced anaesthesia residents performed laryngoscopies with both devices in a randomised sequence., Main Outcome Measures: The primary outcome was peak force. The secondary outcomes were average force and impulse force. The latter is the integral of the force over the time during which the force acted., Results: Complete data were available for 40 individuals. Peak and average forces decreased with GlideScope (17 vs. 21 N, P = 0.03, and 6 vs. 11 N, P < 0.001, respectively). Laryngoscopy time increased with the GlideScope (30 vs. 18 s, P < 0.001), resulting in similar median impulse forces (206 vs. 175 N, P = 0.92)., Conclusion: GlideScope laryngoscopy resulted in reduced peak and average forces, but as the laryngoscopy duration increased, the product of force and time (impulse force) was similar with both devices., Trial Registration: Clinicaltrials.gov Identifier: NCT01814176.

Objective: Laryngeal endoscopy with stroboscopy, a critical component of the assessment of voice disorders, is rarely used as a treatment outcome measure in the scientific literature. We hypothesized that this is because of the lack of a widely used standardized, validated, and reliable method to assess and report laryngeal anatomy and physiology, and undertook a systematic literature review to determine the extent of the inconsistencies of the parameters and scales used in voice treatment outcome studies., Study Design: Systematic literature review., Methods: We searched PubMed, Ovid, and Cochrane for studies where laryngeal endoscopy with stroboscopy was used as a treatment outcome measure with search terms representing "stroboscopy" and "treatment" guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards., Results: In the 62 included articles, we identified 141 terms representing 49 different parameters, which were further classified into 20 broad categories. The six most common parameters were magnitude of glottal gap, mucosal wave amplitude, location or shape of glottal gap, regularity of vibration, phase symmetry, and presence and size of specific lesions. Parameters were assessed on scales ranging from binary to 100 points. The number of scales used for each parameter varied from 1 to 24, with an average of four different scales per parameter., Conclusions: There is a lack of agreement in the scientific literature regarding which parameters should be assessed to measure voice treatment outcomes and which terms and scales should be used for each parameter. This greatly diminishes comparison and clinical implementation of the results of treatment outcomes research in voice disorders. We highlight a previously published tool and recommend it for future use in research and clinical settings., (Copyright © 2018. Published by Elsevier Inc.)

Background: For critically ill patients, effective airway management with a high first-attempt success rate for endotracheal intubation is essential to prevent hypoxic complications during securing of the airway. Video guidance may improve first-attempt success rate over direct laryngoscopy (DL)., Methods: With ethics approval, this randomised controlled trial involved 54 critically ill patients who received endotracheal intubation using a tube with an integrated video camera (VivaSight™-SL tube, VST, ETView Ltd., Misgav, Israel) or using conventional intubation under DL., Results: The two groups did not differ in terms of intubation conditions. The first-attempt success rate was VST 96% vs. DL 93% (not statistically significant (n. s.)). When intubation at first attempt failed, it was successful in the second attempt in all patients. There was no difference in the median average time to intubation (VST 34 s (interquartile range 28-39) vs. DL 35 s (28-40), n. s.). Neither vomiting nor aspiration or accidental oesophageal intubation were observed in either group. The lowest pulsoxymetric oxygen saturation for VST was 96 (82-99) % vs. 99 (95-100) % for DL (n. s.). Hypotension defined as systolic blood pressure < 70 mmHg occurred in the VST group at 20% vs. the DL group at 15% (n. s.)., Conclusion: In this pilot study, no advantage was shown for the VST. The VST should be examined further to identify patient groups that could benefit from intubation with the VST, that is, patients with difficult airway conditions., Trial Registration: ClinicalTrials.gov, NCT02837055 . Registered on 13 June 2016.

Introduction: Airway management is a critical skill for air medical providers, including the use of rapid sequence intubation (RSI) medications. Mediocre success rates and a high incidence of complications has challenged air medical providers to improve training and performance improvement efforts to improve clinical performance., Objectives: The aim of this research was to describe the experience with a novel, integrated advanced airway management program across a large air medical company and explore the impact of the program on improvement in RSI success., Methods: The Helicopter Advanced Resuscitation Training (HeART) program was implemented across 160 bases in 2015. The HeART program includes a novel conceptual framework based on thorough understanding of physiology, critical thinking using a novel algorithm, difficult airway predictive tools, training in the optimal use of specific airway techniques and devices, and integrated performance improvement efforts to address opportunities for improvement. The C-MAC video/direct laryngoscope and high-fidelity human patient simulation laboratories were implemented during the study period. Chi-square test for trend was used to evaluate for improvements in airway management and RSI success (overall intubation success, first-attempt success, first-attempt success without desaturation) over the 25-month study period following HeART implementation., Results: A total of 5,132 patients underwent RSI during the study period. Improvements in first-attempt intubation success (85% to 95%, p < 0.01) and first-attempt success without desaturation (84% to 94%, p < 0.01) were observed. Overall intubation success increased from 95% to 99% over the study period, but the trend was not statistically significant (p = 0.311)., Conclusions: An integrated advanced airway management program was successful in improving RSI intubation performance in a large air medical company.

Purpose: The aim of this study was to recommend protocols for instrumental assessment of voice production in the areas of laryngeal endoscopic imaging, acoustic analyses, and aerodynamic procedures, which will (a) improve the evidence for voice assessment measures, (b) enable valid comparisons of assessment results within and across clients and facilities, and (c) facilitate the evaluation of treatment efficacy., Method: Existing evidence was combined with expert consensus in areas with a lack of evidence. In addition, a survey of clinicians and a peer review of an initial version of the protocol via VoiceServe and the American Speech-Language-Hearing Association's Special Interest Group 3 (Voice and Voice Disorders) Community were used to create the recommendations for the final protocols., Results: The protocols include recommendations regarding technical specifications for data acquisition, voice and speech tasks, analysis methods, and reporting of results for instrumental evaluation of voice production in the areas of laryngeal endoscopic imaging, acoustics, and aerodynamics., Conclusion: The recommended protocols for instrumental assessment of voice using laryngeal endoscopic imaging, acoustic, and aerodynamic methods will enable clinicians and researchers to collect a uniform set of valid and reliable measures that can be compared across assessments, clients, and facilities.

Background: Unpredictable difficult laryngoscopy remains a challenge for anaesthesiologists, especially if difficult ventilation occurs during standard laryngoscopy. Accurate airway assessment should always be performed, but the common clinical screening tests have shown low sensitivity and specificity with a limited predictive value. Ultrasound-based airway assessment has been proposed recently as a useful, simple, noninvasive bedside tool as an adjunct to clinical methods, but to date, few studies are available about the potential role of ultrasound in difficult airway evaluation, and these are mostly limited to specific groups of patients., Objectives: The aim of this study was to determine the correlation between the sonographic measurements of anterior cervical soft tissues thickness and Cormack-Lehane grade view at direct laryngoscopy in patients with normal clinical screening tests., Design: Prospective, single blinded, observational study., Setting: Operating theatre of a teaching hospital from May 2017 to September 2017., Patients: A total of 301 patients at least 18 years of age undergoing elective surgery under general anaesthesia with tracheal intubation were included in the study., Outcome Measures: Pre-operative evaluation was performed before surgery, demographic variables were collected and clinical screening tests to predict a difficult airway were performed. Patients with predicted difficult intubation were excluded. A 10 to 13-MHz linear ultrasound transducer was placed in the transverse plane and the thickness of the anterior cervical soft tissues was measured at two levels [thyrohyoid membrane (pre-epiglottic space) and vocal cords (laryngeal inlet)] with the patient's head in a neutral position. At each level, the distance from the skin in the median axis and the surrounding area was measured. The laryngoscopic view was graded by a different anaesthetist with more than 5 years of experience with direct laryngoscopy, blinded to the ultrasound assessments., Results: The 'pre-epiglottic space thickness' at the level of thyrohyoid membrane was measured as the median distance from skin to epiglottis (mDSE) and the pre-epiglottic area was calculated; the mDSE cut-off value of 2.54 cm (sensitivity 82%, specificity 91%) and the pre-epiglottic area cut-off value of 5.04 cm (sensitivity 85%, specificity 88%) were the best predictors of a Cormack-Lehane grade at least 2b at direct laryngoscopy and of difficult intubation. The cut-off value of mDSE showed greater sensitivity in female patients (94 vs. 86%) and greater specificity in male patients (92 vs. 83%). No correlation was found between difficult laryngoscopy and ultrasound assessments at the level of the vocal cords., Conclusion: Airways ultrasounds might be considered as a predictor of restricted/difficult laryngoscopy and unpredicted difficult intubation., Trial Registration: ClinicalTrials.gov: NCT03547193.

Objective To review complications of in-office endoscopic laryngeal laser procedures after implementation of standardized safety protocol. Methods A retrospective review was conducted of the first 2 years of in-office laser procedures at St Michaels Hospital after the introduction of a standardized safety protocol. The protocol included patient screening, procedure checklist with standardized reporting of processes, medications, and complications. Primary outcomes measured were complication rates of in-office laryngeal laser procedures. Secondary outcomes included hemodynamic changes, local anesthetic dose, laser settings, total laser/procedure time, and incidence of sedation. Results A total of 145 in-office KTP procedures performed on 65 patients were reviewed. In 98% of cases, the safety protocol was fully implemented. The overall complication rate was 4.8%. No major complications were encountered. Minor complications included vasovagal episodes and patient intolerance. The rate of patient intolerance resulting early termination of anticipated procedure was 13.1%. Total local anesthetic dose averaged 172.9 mg lidocaine per procedure. The mean amount of laser energy dispersed was 261.2 J, with mean total procedure time of 48.3 minutes. Sixteen percent of patients had preprocedure sedation. Vital signs were found to vary modestly. Systolic blood pressure was lower postprocedure in 13.8% and symptomatic in 4.1%. Discussion The review of our standardized safety protocol has revealed that in-office laser treatment for laryngeal pathology has extremely low complication rates with safe patient outcomes. Implications for Practice The trend of shifting procedures out of the operating room into the office/clinic setting requires new processes designed to promote patient safety.

Background: Emergency intubation carries a higher risk of complications than elective airway management. Video laryngoscopy (VL) could potentially improve patient safety. The goal of this study was to determine whether VL is superior to direct laryngoscopy for the emergency intubation of adults in the inpatient setting., Methods: Pertinent studies were retrieved by a systematic literature search in the MEDLINE, Embase, and CENTRAL databases. The selection of studies, data extraction, and assessment of the potential for bias were carried out independently by two of the authors. Effect sizes were reported as odds ratios (OR) or mean differences (MD). The primary endpoint was successful intubation at the first attempt. Further variables were considered as secondary endpoints., Results: 1098 titles and abstracts were retrieved, and the full texts of 43 articles were examined. Eight randomized and controlled trials, with a total of 1796 patients, were analyzed. VL was not found to confer any statistically significant advantage with respect to successful intubation at the first attempt (OR 0.72, 95% confidence interval [0.47; 1.12]) or with respect to the time to successful intubation (MD -8.99 seconds [-24.00; 6.01]). On the other hand, the use of VL was significantly associated with a lower number of intubation attempts (MD -0.17 [-0.31; -0.03]) and with a lower frequency of esophageal intubation (OR 0.27 [0.10; 0.75])., Conclusion: The routine use of VL for airway management in emergency medicine might improve patient safety, as VL is associated with a lower number of intubation attempts and with a lower frequency of esophageal intubation. Further randomized controlled trials are needed before any definitive conclusions can be drawn about the advantages of video laryngoscopy.

Objectives: In the last decade, the practice of intubation in the intensive care unit (ICU) has evolved. To further examine the current intubation practice in the ICU, we administered a survey to critical care physicians., Design: Cross-sectional survey study design., Setting: Thirty-two academic/nonacademic centers nationally and internationally., Measurements and Main Results: The survey was developed among a core group of physicians with the assistance of the Survey Research Center at Mayo Clinic, Rochester, Minnesota. The survey was pilot tested for functionality and reliability. The response rate was 82 (51%) of 160 among the 32 centers. Although propofol was the induction drug of choice, there was a significant difference with actual ketamine use and those who indicated a preference for it (ketamine: 52% vs 61%; P < .001). The most common airway device used for intubation was direct laryngoscopy (Miller laryngoscope blade) at 56 (68%) followed by video laryngoscopy at 26 (32%). Most (>90%) indicated that they have a difficult airway cart, but only 55 (67%) indicated they have a documented plan to handle a difficult airway with even lower results for documented review of adverse events (49%)., Conclusion: Although propofol was the induction drug of choice, ketamine was a medication that many preferred to use, possibly relating to the fact that the most common complication postintubation is hypotension. Direct laryngoscopy remains the primary airway device for endotracheal intubation. Finally, although the majority stated they had a difficult airway cart available, most did not have a documented plan in place when encountering a difficult airway or a documented process to review adverse events surrounding intubation.

Background: Videolaryngoscopy is a valuable technique for endotracheal intubation. When used in the perioperative period, different videolaryngoscopes vary both in terms of technical use and intubation success rates. However, in the prehospital environment, the relative performance of different videolaryngoscopic systems is less well studied., Methods: We conducted this prospective, randomized, multicenter study at 4 German prehospital emergency medicine centers. One hundred sixty-eight adult patients requiring prehospital emergency intubation were treated by an emergency physician and randomized to 1 of 3 portable videolaryngoscopes (A.P. Advance, C-MAC PM, and channeled blade KingVision) with different blade types. The primary outcome variable was overall intubation success and secondary outcomes included first-attempt intubation success, glottis visualization, and difficulty with handling the devices. P values for pairwise comparisons are corrected by the Bonferroni method for 3 tests (P[BF]). All presented P values are adjusted for center., Results: Glottis visualization was comparable with all 3 devices. Overall intubation success for A.P. Advance, C-MAC, and KingVision was 96%, 97%, and 61%, respectively (overall: P < .001, A.P. Advance versus C-MAC: odds ratio [OR], 0.97, 95% confidence interval [CI], 0.13-7.42, P[BF] > 0.99; A.P. Advance versus KingVision: OR, 0.043, 95% CI, 0.0088-0.21, P[BF] < 0.001; C-MAC versus KingVision: OR, 0.043, 95% CI, 0.0088-0.21, P[BF] < 0.001). Intubation success on the first attempt with A.P. Advance, C-MAC, and KingVision was 86%, 85%, and 48%, respectively (overall: P < .001, A.P. Advance versus C-MAC: OR, 0.89, 95% CI, 0.31-2.53, P[BF] > 0.99; A.P. Advance versus KingVision: OR, 0.24, 95% CI, 0.055-0.38, P[BF] = 0.0054; C-MAC versus KingVision: OR, 0.21, 95% CI, 0.043-.34, P[BF] < 0.003). Direct laryngoscopy for successful intubation with the videolaryngoscopic device was necessary with the A.P. Advance in 5 patients, and with the C-MAC in 4 patients. In the KingVision group, 21 patients were intubated with an alternative device., Conclusions: During prehospital emergency endotracheal intubation performed by emergency physicians, success rates of 3 commercially available videolaryngoscopes A.P. Advance, C-MAC PM, and KingVision varied markedly. We also found that although any of the videolaryngoscopes provided an adequate view, actual intubation was more difficult with the channeled blade KingVision.

Purpose: Proper training and assessment of skill in flexible pharyngo-laryngoscopy are central in the education of otorhinolaryngologists. To facilitate an evidence-based approach to curriculum development in this field, a structured analysis of what constitutes flexible pharyngo-laryngoscopy is necessary. Our aim was to develop an assessment tool based on this analysis., Methods: We conducted an international Delphi study involving experts from twelve countries in five continents. Utilizing reiterative assessment, the panel defined the procedure and reached consensus (defined as 80% agreement) on the phrasing of an assessment tool., Results: FIFTY PANELISTS COMPLETED THE DELPHI PROCESS. THE MEDIAN AGE OF THE PANELISTS WAS 44 YEARS (RANGE 33-64 YEARS). MEDIAN EXPERIENCE IN OTORHINOLARYNGOLOGY WAS 15 YEARS (RANGE 6-35 YEARS). TWENTY-FIVE WERE SPECIALIZED IN LARYNGOLOGY, 16 WERE HEAD AND NECK SURGEONS, AND NINE WERE GENERAL OTORHINOLARYNGOLOGISTS. AN ASSESSMENT TOOL WAS CREATED CONSISTING OF TWELVE DISTINCT ITEMS.: Conclusion The gathering of validity evidence for assessment of core procedural skills within Otorhinolaryngology is central to the development of a competence-based education. The use of an international Delphi panel allows for the creation of an assessment tool which is widely applicable and valid. This work allows for an informed approach to technical skills training for flexible pharyngo-laryngoscopy and as further validity evidence is gathered allows for a valid assessment of clinical performance within this important skillset.

Background: The surgical plethysmographic index (SPI) is one of the available indexes of the nociception-antinociception (NAN) balance. Individually adjusting the NAN balance to prevent somatic responses to noxious stimulation remains a challenge., Objectives: To assess whether guiding remifentanil administration according to the SPI response to a calibrated noxious stimulus (NANCAL) can blunt the haemodynamic response to tracheal intubation and surgical incision., Design: Randomised multicentre study., Setting: Two Belgian university hospitals from January 2014 to April 2015., Patients: After ethic review board approval and informed consent, 48 American Society of Anesthesiologists I or II adult patients scheduled for surgery under general anaesthesia were enrolled., Interventions: Patients were randomly assigned to a SPI group, where remifentanil effect-site concentration was adjusted according to NANCAL, or a control group, where it was fixed at 4 ng ml. Propofol concentration was always adjusted to maintain the bispectral index close to 40. NANCAL consisted of a 100 Hz, 60 mA electrical tetanic stimulation during 30 s at the wrist before tracheal intubation and before surgical incision., Main Outcome Measures: The primary endpoint was the efficacy of the NANCAL-guided remifentanil administration to prevent the haemodynamic response to tracheal intubation and surgical incision. The secondary aim was to compare the ability of SPI, analgesia nociception index, pupil diameter and mean arterial pressure response to NANCAL to predict the haemodynamic response to tracheal intubation and surgical incision., Results: Our SPI response to NANCAL-based correcting scheme for remifentanil administration was not superior to a fixed remifentanil concentration at blunting the haemodynamic response to tracheal intubation or surgical incision. Among all tested NAN balance indices, only mean arterial pressure had significant predictive ability with regard to the haemodynamic response to surgical incision., Conclusion: Further research is needed to define the best NANCAL stimulus and the best remifentanil correcting scheme to help individualised tailoring of antinociception for each specific subpopulation of surgical patients., Trial Registration: Clinicaltrials.gov NCT: 02884310; https://clinicaltrials.gov/ct2/show/NCT02884310.

Objectives: To test the hypothesis that laryngoscopy using the Airtraq (Prodol Limited, Viscaya, Spain) or King Vision laryngoscope (KVL) (Ambu A/S, Ballerup, Denmark) would result in a shorter time for successful double-lumen endobronchial tube (DLT) intubation by users with mixed experience than the time required using the Macintosh or GlideScope (Verathon Inc., Bothell, WA) laryngoscopes., Design: A randomized, prospective, blind study., Setting: A single university hospital., Participants: The study comprised 133 patients undergoing elective thoracic surgery., Interventions: Patients were randomly allocated into the following 4 groups of DLTs: Macintosh (n = 32), GlideScope (n = 34), Airtraq (n = 35), or KVL (n = 32)., Measurements and Main Results: The following data were recorded: time required for achieving successful DLT intubation; glottis visualization; optimization maneuvers; first-pass success rate; intubation difficulty; failure to intubate, defined as an attempt taking >150 seconds to perform or if peripheral oxygen saturation <92% was noted; and postoperative sore throat and hoarseness were recorded. Compared with GlideScope, the Airtraq resulted in shorter times for achieving successful DLT intubation (median times: 21 s [95% confidence interval 23.9-70.8 s] v 57.5 s [95% confidence interval 46.2-89.1 s], respectively; p = 0.021); a lower score for difficult intubations (p = 0.023); and fewer optimization maneuvers. The 4 laryngoscopes were associated with comparable glottis visualization; first-pass success rate (100%, 100%, 94.4%, and 100%, respectively; p = 0.522); incidence of oropharyngeal trauma; postoperative sore throat; and hoarseness of voice. There were 2 (5.7%) endobronchial intubation failures using the Airtraq due to the inability to advance the DLT through the glottis opening. The experience of the anesthesiologists in using the 4 devices had a statistically significant negative correlation with the time to confirmation of endobronchial intubation (Spearman r -0.392; p < 0.001)., Conclusion: When used by operators with mixed experience, the channeled Airtraq required less time for DLT intubation and was easier to use than the GlideScope, although failures did occur with the Airtraq, whereas they did not occur with the other systems., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: McGrath MAC video laryngoscope offers excellent laryngosopic views and increases the success rate of orotracheal intubation in some cases. The aim of this study was to determine the usefulness of McGrath MAC for routine nasotracheal intubation by comparing McGrath MAC with Airway scope and Macintosh laryngoscope., Methods: A total of 60 adult patients with ASA physical status class 1 or 2, aged 20-70 years were enrolled in this study. Patients were scheduled for elective oral surgery under general anesthesia with nasotracheal intubation. Exclusion criteria included lack of consent and expected difficult airway. Patients were randomly allocated to three groups: McGrath MAC (n = 20), Airway scope (n = 20), and Macintosh laryngoscope (n = 20). After induction, nasotracheal intubation was performed by six expert anesthesiologists with more than 6 years of experience., Results: There were no significant differences in preoperative airway assessment among the three groups. Successful tracheal intubation time was 26.8 ± 5.7 (mean ± standard deviation) s for McGrath MAC, 36.4 ± 11.0 s for Airway scope, and 36.5 ± 8.9 s for Macintosh laryngoscope groups. The time for successful tracheal intubation for McGrath MAC group was significantly shorter than that for Airway scope and Macintosh laryngoscope (p < 0.01). McGrath MAC significantly improved the Cormack Lehane grade for nasotracheal intubation compared with Macintosh laryngoscope (p < 0.05)., Conclusion: McGrath MAC significantly facilitates routine nasotracheal intubation compared with Airwayscope and Macintosh laryngoscope by shortening the tracheal intubation time and improving the Cormack Lehane grade., Trial Registration: UMINCTR Registration number UMIN000023506 . Registered 5 Aug 2016.

The purpose of this investigation was to investigate the association between first attempt success and intubation-related complications in the Intensive Care Unit after the widespread adoption of video laryngoscopy. We further sought to characterize and identify the predictors of complications that occur despite first attempt success. This was a prospective observational study of consecutive intubations performed with video laryngoscopy at an academic medical Intensive Care Unit. Operator, procedural, and complication data were collected. Multivariable logistic regression was used to examine the relationship between the intubation attempts and the occurrence of one or more complications. A total of 905 patients were intubated using a video laryngoscope. First attempt success occurred in 739 (81.7 %), whereas >1 attempt was needed in 166 (18.3 %). One or more complications occurred in 146 (19.8 %) of those intubated on the first attempt versus 107 (64.5 %, p < 0.001) of those requiring more than one attempt. Logistic regression analysis shows that >1 attempt is associated with 6.4 (95 % CI 4.4-9.3) times the adjusted odds of at least one complication. Pre-intubation predictors of at least one complication despite first attempt success include vomit or edema in the airway as well as the presence of hypoxemia or hypotension. There are increased odds of complications with even a second attempt at intubation in the Intensive Care Unit. Complications occur frequently despite a successful first attempt, and as such, the goal of airway management should not be simply first attempt success, but instead first attempt success without complications.

Background: There is significant controversy regarding the influence of video laryngoscopy on the intubation outcomes in emergency and critical patients. This systematic review and meta-analysis was designed to determine whether video laryngoscopy could improve the intubation outcomes in emergency and critical patients., Methods: We searched the Cochrane Central Register of Controlled Trials, PubMed, Embase, and Scopus databases from database inception until 15 February 2017. Only randomized controlled trials comparing video and direct laryngoscopy for tracheal intubation in emergency department, intensive care unit, and prehospital settings were selected. The primary outcome was the first-attempt success rate. Review Manager 5.3 software was used to perform the pooled analysis and assess the risk of bias for each eligible study. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to assess the quality of evidence for all outcomes., Results: Twelve studies (2583 patients) were included in the review for data extraction. Pooled analysis did not show an improved first-attempt success rate using video laryngoscopy (relative risk [RR], 0.93; P = 0.28; low-quality evidence). There was significant heterogeneity among studies (I 2  = 91%). Subgroup analyses showed that, in the prehospital setting, video laryngoscopy decreased the first-attempt success rate (RR, 0.57; P < 0.01; high-quality evidence) and overall success rate (RR, 0.58; 95% CI, 0.48-0.69; moderate-quality evidence) by experienced operators, whereas in the in-hospital setting, no significant difference between two devices was identified for the first-attempt success rate (RR, 1.06; P = 0.14; moderate-quality evidence), regardless of the experience of the operators or the types of video laryngoscopes used (P > 0.05), although a slightly higher overall success rate was shown (RR, 1.11; P = 0.03; moderate-quality evidence). There were no differences between devices for other outcomes (P > 0.05), except for a lower rate of esophageal intubation (P = 0.01) and a higher rate of Cormack and Lehane grade 1 (P < 0.01) when using video laryngoscopy., Conclusions: On the basis of the results of this study, we conclude that, compared with direct laryngoscopy, video laryngoscopy does not improve intubation outcomes in emergency and critical patients. Prehospital intubation is even worsened by use of video laryngoscopy when performed by experienced operators.

Background: Positioning of a lightwand in the midline of the oral cavity can be challenging in patients with cervical immobilization. Direct laryngoscopy may permit the lightwand tip to more easily access the glottic opening. We tested our hypothesis that a laryngoscope-assisted lightwand technique allows more successful endotracheal intubation than does a conventional lightwand approach., Methods: A total of 162 patients requiring cervical immobilization during intubation for cervical spine surgery were allocated randomly to 2 groups. The conventional lightwand technique (group C, n = 80) or the laryngoscope-assisted lightwand technique (group L, n = 82) was used for endotracheal intubation. In the group L, a Macintosh laryngoscope was inserted into the oral cavity, advanced until the epiglottis tip was visible, but not used to lift the epiglottis tip. The lightwand tip was placed below the epiglottis under direct view of the epiglottis tip. The primary outcome (the initial intubation success rate) and secondary outcomes (intubation time, hemodynamic changes, and postoperative airway complications) were evaluated., Results: The initial intubation success rate was significantly lower (75% vs 89%; relative risk [95% confidence interval]: 1.2 [1.0-1.4]; P = .034) in group C than group L. The intubation time (22 ± 13 vs 24 ± 12 seconds; mean difference [98.33% confidence interval]: 2.4 [-2.3 to 7.2]; P = .217) did not differ between groups. Postoperative sore throat score, incidences of hypertension and tachycardia, postoperative oral mucosal bleeding, and hoarseness also did not differ between groups., Conclusions: Laryngoscope-assisted lightwand intubation did not increase intubation time, and it increased first attempt intubation rates compared with traditional lightwand intubation in patients requiring cervical immobilization for cervical spine surgery.

Background: To study the impact of videolaryngoscopy (VL) on intubation success among pediatric trainees compared with direct laryngoscopy (DL)., Methods: One hundred pediatric residents were enrolled in a randomized, crossover, simulation study comparing VL to DL. Following a didactic session on neonatal intubation, residents intubated a standard neonatal mannequin. Three Neonatal Resuscitation Program (NRP) scenarios were then conducted, followed by a mannequin intubation with the alternate device. Number of attempts and time to intubation were recorded for all intubations., Results: Proportion of successful intubations on first attempt was greater with VL compared with DL (88% versus 63%; P=0.008). The DL group increased success after crossover with VL (63% versus 89%; P=0.008). Exposure to VL also reduced intubation time after device crossover (median intubation time: 31 versus 17 s; P=0.048)., Conclusions: VL increased the success of endotracheal intubation by pediatric residents in simulation, with skills transferrable to DL.

Background: The critically ill or injured patient undergoing military medical evacuation may require emergent intubation. Intubation may be life-saving, but it carries risks. The novice or infrequent laryngoscopist has a distinct disadvantage because experience is critical for the rapid and safe establishment of a secured airway. This challenge is compounded by the austere environment of the back of an aircraft under blackout conditions. This study determined which of five different video-assisted intubation devices (VAIDs) was best suited for in-flight use by U.S. Air Force Critical Care Air Transport Teams by comparing time to successful intubation between novice and expert laryngoscopists under three conditions, Normal Airway Lights on (NAL), Difficult Airway Lights on (DAL) and Difficult Airway Blackout (DAB), using manikins on a standard military transport stanchion and the floor with a minimal amount of setup time and extraneous light emission., Methods: A convenience sample size of 40 participants (24 novices and 16 experts) attempted intubation with each of the 5 different video laryngoscopic devices on high-fidelity airway manikins. Time to tracheal intubation and number of optimization maneuvers used were recorded. Kruskal-Wallis testing determined significant differences between the VAIDs in time to intubation for each particular scenario. Devices with significant differences underwent pair-wise comparison testing using rank-sum analysis to further clarify the difference. Device assembly times, startup times and the amount of light emitted were recorded. Perceived ease of use was surveyed., Results: Novices were fastest with the Pentax AWS in all difficult airway scenarios. Experts recorded the shortest median times consistently using 3 of the 5 devices. The AWS was superior overall in 4 of the 6 scenarios tested. Experts and novices subjectively judged the GlideScope Ranger as easiest to use. The light emitted by all the devices was less than the USAF-issued headlamp., Conclusions: Novices intubated fastest with the Pentax AWS in all difficult airway scenarios. The GlideScope required the shortest setup time, and participants judged this device as the easiest to use. The GlideScope and AWS exhibited the two fastest total setup times. Both devices are suitable for in-flight use by infrequent and seasoned laryngoscopists.