British Journal of Anaesthesia 102 (5): 65461 (2009)

doi:10.1093/bja/aep056

Advance Access publication March 31, 2009

CRITICAL CARE
Tracheal intubation in patients with cervical spine immobilization:
a comparison of the Airwayscopew, LMA CTrachw, and the
Macintosh laryngoscopes
M. A. Malik1 2, R. Subramaniam1, S. Churasia1, C. H. Maharaj3, B. H. Harte1
and J. G. Laffey1 2*
1

Department of Anaesthesia, Galway University Hospitals and 2Clinical Research Facility, National
University of Ireland, Galway, Ireland. 3Department of Anaesthesia, Sligo General Hospital, Sligo, Ireland
*Corresponding author. E-mail: john.laffey@nuigalway.ie
Background. The purpose of this study was to evaluate the effectiveness of the Pentax
AWSw, and the LMA CTrachw, in comparison with the Macintosh laryngoscope, when performing tracheal intubation in patients with neck immobilization using manual in-line axial cervical
spine stabilization.
Methods. Ninety patients undergoing anaesthesia who required tracheal intubation were randomly assigned to undergo intubation using a Macintosh (n30), LMA CTrachw (n30), or
AWSw (n30) laryngoscope. All patients were intubated by one of the three anaesthetists familiar with the use of each laryngoscope.
Results. The intubation difficulty scores were significantly higher with the Macintosh laryngoscope and were significantly lower with the AWSw compared with the LMA CTrach. All 30
patients were successfully intubated with the Macintosh and the AWSw device, compared with
27 patients with the LMA CTrachw. The duration of both the first and the successful tracheal
intubation attempts was significantly longer with the LMA CTrachw compared with the AWSw
and Macintosh laryngoscopes. A greater number of optimization manoeuvres were required to
facilitate tracheal intubation with the LMA CTrachw compared with the AWSw laryngoscope.
The AWSw group had a significantly better Cormack and Lehane glottic view obtained at laryngoscopy compared with both other devices.
Conclusions. The AWSw laryngoscope has several advantages over the Macintosh laryngoscope, or LMA CTrachw, in patients undergoing cervical spine immobilization.
Br J Anaesth 2009; 102: 65461
Keywords: equipment, AWSw laryngoscope; equipment, Macintosh laryngoscope; difficult
intubation; intubation, tracheal; LMA CTrachw; neck immobilization
Accepted for publication: February 19, 2009

Failure to adequately immobilize the neck during tracheal

intubation in patients with cervical spine injuries can
result in devastating neurologic outcomes.1 Anatomic
studies that mimic complete C4 5 ligamentous injury
demonstrate that manual in-line axial stabilization reduces
segmental angular rotation and distraction.2 Consequently,
in many institutions, where tracheal intubation is required
in patients with potential cervical spine injuries, the rigid
cervical collar is removed, and the cervical spine immobilized by means of manual in-line axial stabilization.

However, a key concern is the fact that with cervical spine

immobilization, it is more difficult to visualize the larynx
using conventional laryngoscopy.3 5 Failure to successfully intubate the trachea and secure the airway remains a
leading cause of morbidity and mortality, in the operating
theatre,6 8 and in the emergency setting.9
Efforts to reduce the difficulty of tracheal intubation
have prompted the development of a number of alternatives to Macintosh laryngoscope. The AWSw (Pentax
Corporation, Tokyo, Japan)10 12 consists of a disposable

# The Author [2009]. Published by Oxford University Press on behalf of The Board of Directors of the British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: journals.permissions@oxfordjournal.org

Immobile cervical spine and laryngoscopy

Fig 1 (A) Photograph of the Pentax AWSw laryngoscope with a single-use blade clipped onto a camera system. (B) Photograph of the LMA CTrachw.
The tracheal tube is passed through the LMA while glottic inlet is viewed on the screen.

transparent blade which fits over a 12 cm fibreoptic cable

linked to a charge-coupled device camera, and a 2.4 in
colour liquid crystal display screen (Fig. 1A). The LMA
CTrachw (Intavent Orthofix Ltd, Maidenhead, UK) is a
modified laryngeal mask airway, which incorporates an
inbuilt integrated fibreoptic system and a detachable liquid
crystal display colour viewer with a light source that facilitates visualization of glottis during intubation (Fig. 1B).
Advantages over the Macintosh have been demonstrated
for the LMA CTrachw in patients with normal airways13 14
and in morbidly obese patients.15 The efficacy of the LMA
CTrachw has not been compared with the Macintosh in
patients undergoing cervical spine immobilization. The
Pentax AWSw has been demonstrated to perform better
than the Macintosh in patients undergoing cervical spine
immobilization.10 11 However, the relative efficacies of
these devices in comparison with the Macintosh have not
been compared in a single study.
The purpose of this clinical trial was to evaluate the
relative efficacy of the LMA CTrachw and the AWSw laryngoscopes when used by experienced anaesthetists in
patients undergoing neck immobilization by manual
in-line axial stabilization, and to compare their performance with the Macintosh laryngoscope. We hypothesized
that, in comparison with the Macintosh, these novel laryngoscopes would reduce intubation difficulty, as measured
by the intubation difficulty scale (IDS) score. We further
hypothesized that the AWS would reduce intubation difficulty compared with the LMA CTrach in this setting.

Methods
After obtaining approval by the Galway University
Hospitals Research Ethics Committee (Galway, Ireland),
and written informed patient consent, we studied 90 ASA
I III patients, aged 16 yr or older, undergoing general

anaesthesia for surgery and requiring tracheal intubation.

The study was done in a manner of a randomized, single
blind, controlled clinical trial. Patients were excluded if
risk factors for gastric aspiration, difficult intubation
(Mallampatti class III or IV; thyromental distance ,6 cm;
and inter-incisor distance ,3.5 cm), or both were present,
or where there was a history of relevant drug allergy. All
data were collected by an independent unblinded observer.
The allocation sequence was generated by random number
tables, and the allocation concealed in sealed envelopes,
which were not opened until patient consent had been
obtained. Patients were randomized to tracheal intubation
with either the Macintosh (size 3 blade in females; size 4
in males), the CTrach,w or the AWSw laryngoscopes.
All patients received a standardized general anaesthetic.
Standard monitoring included ECG, non-invasive arterial
pressure, SpO2, and measurement of end-tidal carbon
dioxide and volatile anaesthetic levels. Bispectral Index
(BISw) (Aspect Medical Systems, Norwood, MA, USA) or
Entropyw (GE Healthcare, Helsinki, Finland) monitoring
was utilized in all patients. Before induction of anaesthesia, all patients were given fentanyl 1 1.5 mg kg21 i.v.
Propofol 2 4 mg kg21 was titrated to induce anaesthesia
in a dose sufficient to produce loss of verbal response.
After induction of anaesthesia, all patients were manually
ventilated with sevoflurane 2.0 2.5% in oxygen, and atracurium 0.5 mg kg21 was administered. Tracheal intubation
was not performed until the BIS/Entropy score had
decreased below 60, and additional boluses of propofol
were administered to increase depth of anaesthesia if
required. Three minutes after the administration of neuromuscular block, the pillow was removed and the neck
immobilized using manual in-line axial stabilization
applied by an experienced anaesthetist holding the sides of
the neck and the mastoid processes, thus preventing
flexion/extension or rotational movement of the head
and neck.

655

Malik et al.

Tracheal intubation was performed in each patient by

one of the three anaesthetists (M.A.M., R.S., and S.C.)
who were familiar with each of the devices. Each investigator had performed, with each device, at least 50 intubations in manikins and at least 20 intubations in the clinical
setting. The tracheal tube was placed in the side channel
of the Pentax AWSw laryngoscope in advance of the intubation attempt. The AWSw was inserted into the mouth in
the midline and advanced slowly over the tongue along
the palatal wall, until the epiglottis came into view. The
blade was then advanced under the epiglottis, and the
glottis was seen. The target symbol was aligned with
the glottic opening, the tracheal tube was gently advanced
through the glottis, then detached from the blade, and the
AWSw blade was removed.
The CTrachw was inserted into the laryngopharynx, the
cuff was inflated, and the position adjusted as necessary
until effective ventilation was established. The viewer was
then attached and the CTrachw adjusted to optimize the
view of the glottis. Where the epiglottis was obstructing
the view of the glottis, an up down Chandy manoeuvre
was performed by withdrawing the LMA CTrachw 6 cm
and reinserting it with cuff still inflated. These manoeuvres
were repeated as required to correct epiglottic downfolding, and tracheal intubation was performed once the view
of the glottis had been optimized. If a clear view of the
glottis was not obtainable, an attempt was still made to
perform tracheal intubation using the best view obtainable.
The trachea was then intubated with a 7.5 mm tracheal
tube in females, and an 8.0 mm tracheal tube in males, by
one of the investigators. In patients intubated using the
LMA CTrachw, the disposable, flexible, and reinforced
LMA Fastrachw tracheal tube (Laryngeal Mask Company
Ltd, San Diego, CA, USA) was used. A conventional
polyvinylchloride tracheal tube was used in patients intubated with the AWS and Macintosh laryngoscopes. After
successful tracheal intubation, in all patients, the lungs
were mechanically ventilated for the duration of the procedure, and anaesthesia was maintained with sevoflurane
(1.25 1.75%) in a mixture of nitrous oxide and oxygen in
a 2:1 ratio. No other medications were administered, or
procedures performed, during the 5 min data collection
period after tracheal intubation. Subsequent management
was left to the discretion of the anaesthetist providing care
for the patient.
The primary endpoint was the IDS score.16 The IDS
score, developed by Adnet and colleagues,16 is a quantitative scale incorporating multiple indices of intubation difficulty that more objectively quantifies the complexity of
tracheal intubations (Appendix). The secondary endpoints
were the rate of successful placement of the tracheal tube
in the trachea and the duration of the tracheal intubation
procedure. The duration of the intubation attempt was
defined as the time taken from insertion of the blade or
LMA CTrachw between the teeth until the tracheal tube
was placed through the vocal cords, as evidenced by

visual confirmation by the anaesthetist. However, in

patients in whom the tracheal tube was not directly visualized passing through the vocal cords, the intubation
attempt was not considered complete until the tracheal
tube was connected to the anaesthetic circuit and evidence
obtained of the presence of carbon dioxide in the exhaled
breath. In patients intubated with the LMA CTrachw, the
time taken to withdraw the LMA was not included in the
duration of intubation attempts. A failed intubation
attempt was defined as an attempt in which the trachea
was not intubated, or which required .120 s to perform.
In addition, the number of tracheal intubation attempts that
required .60 s was also noted. A maximum of three intubation attempts were permitted. In the event that tracheal
intubation was unsuccessful with the device tested, manual
in-line axial stabilization was discontinued, and tracheal
intubation was performed with the Macintosh laryngoscope. The duration of the first tracheal intubation attempt,
and of the successful attempt in the case that the first
attempt was not successful, was recorded. Additional endpoints included the number of intubation attempts and the
number of optimization manoeuvres required (use of an
airway intubating catheter, cricoid pressure, and second
assistant) to aid tracheal intubation, and the Cormack and
Lehane grade at laryngoscopy.17 The type of airway intubating catheter used was the Frova airway intubating catheter (William Cook Europe Ltd).
We based our sample size estimation on the IDS score.
On the basis of our prior studies, we projected that the
mean IDS score in patients undergoing tracheal intubation
with the Macintosh in the setting of cervical spine immobilization would be 3.0.18 We considered that a clinically
important reduction in mean IDS score would be a
reduction of 2.0. Given an expected standard deviation of
2.25 from prior studies,18 and using an a0.05 and
b0.2, for an experimental design incorporating three
equal-sized groups, we estimated that 26 patients would be
required per group. We therefore aimed to enrol 30
patients per group.
All analyses were performed on an intention-to-treat
basis. Patient characteristic data and data for duration of
intubation attempts and the instrument difficulty score
were analysed using one-way analysis of variance
(ANOVA), except for data for gender which were analysed
using the x2 test. Data for the IDS score, the number of
intubation attempts, and the numbers of optimization
manoeuvres were analysed using ANOVA or Kruskal
Wallis ANOVA on ranks as appropriate. Success of tracheal
intubation was analysed using the x2 test and Fishers
exact test. The comparisons of haemodynamic data were
analysed using two-way repeated-measures ANOVA, with
group and time-point as the factors. In each case, post
hoc between-group testing was performed using the
Student Newman Keuls test. Continuous data are presented as mean (SD), ordinal data are presented as median
(IQR), and categorical data are presented as number and

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Immobile cervical spine and laryngoscopy

Table 1 Patient characteristics. Data are reported as mean (range), mean (SD),
median (IQR), or number
Parameter assessed

Macintosh

AWS

Number per group

Male:female ratio
Age (yr)
BMI (kg m22)
ASA classification
Thyromental distance (cm)
Inter-incisor distance (cm)
Mallampatti classification
Bispectral index or Entropy score
at tracheal intubation

30
18:12
47.4 (18 78)
26.3 (4.9)
II (I, II)
8.4 (1.2)
4.4 (0.5)
II (I, II)
29.0 (10.5)

30
13:17
50.4 (23 82)
26.9 (4.1)
II (I, II)
8.4 (0.9)
4.3 (0.5)
II (I, II)
32.1 (13.5)

Macintosh

26

25

LMA CTrach

Number of patients

30

30
14:16
47.7 (18 78)
24.9 (3.0)
II (I, II)
8.2 (1.1)
4.3 (0.4)
II (I, II)
32.4 (12.6)

Pentax AWS
LMA CTrach

20
15
10

14

8
6

3
1

4
2

0
0

as frequencies. The a-level for all analyses was set as

P,0.05.

2
3
4
5
Intubation difficulty scale score

Fig 2 Comparison of IDS score distributions with each laryngoscope.

The number of patients is shown above each bar. The distribution of IDS
scores in each group is significantly different (P,0.001, KruskalWallis
ANOVA on ranks).

Results
A total of 90 patients were entered into the study.
Ninety-eight patients were consented to participate, but
eight patients were not subsequently entered into the study
due to delays in their surgical procedure taking place.
Thirty patients were randomized to undergo tracheal intubation with each of the three devices. There were no significant differences in characteristics or baseline airway
parameters between the groups (Table 1). There were no
between-group differences with regard to anaesthetic management, including the doses of propofol and fentanyl
administered, the number of additional propofol boluses
required, or in end-tidal sevoflurane concentrations. There
were no between-group differences in BISwor Entropyw
scores immediately before or after tracheal intubation in
both groups (Table 1).
The intubation difficulty scores were significantly higher
with the Macintosh compared with both other devices, and
also significantly higher with the LMA CTrachw compared
with the AWSw laryngoscope (Fig. 2). Of interest, some
of the highest IDS scores were seen with the LMA
CTrachw (Fig. 2). The rate of successful tracheal intubation was significantly lower with the LMA CTrachw compared with both the Macintosh and AWSw laryngosopes.
All 30 patients were successfully intubated with the
Macintosh and the AWSw device, compared with 27
patients with the LMA CTrachw (Table 2). If a lower
maximum time of 60 s was permitted for successful intubation, the success rate for the LMA CTrachw decreased
to 20, whereas there was no difference in the success rates
for the Macintosh or AWS devices. The duration of both
the first and the successful tracheal intubation attempts
was significantly longer with the LMA CTrachw compared
with the AWSw and Macintosh groups (Table 2).
There were no between-group differences in the number
of attempts required with each device (Table 2). However,
a greater number of optimization manoeuvres were
required to facilitate tracheal intubation with the LMA

CTrachw and the Macintosh compared with the AWSw laryngoscope (Table 2). The AWSw group had a significantly
better Cormack and Lehane glottic view obtained at laryngoscopy compared with both other devices (Fig. 3). The
distribution of Cormack and Lehane scores between the
CTrachw and the Macintosh was significantly different,
with more grade 3 4 views with the CTrachw and a predominance of grade 2 views with the Macintosh (Fig. 3).
There were no between-group differences in the incidence of complications, including the appearance of blood
on the laryngoscope blade, or of minor lacerations to the
airway (Table 2). There was no incidence of dental or
more severe airway laceration with any laryngoscope.
Arterial haemoglobin oxygen saturations were well maintained in all groups (Table 2).
The effects of laryngoscopy and tracheal intubation on
the mean arterial blood pressure and heart rate were relatively modest. Heart rate increased significantly in the
LMA CTrachw and Macintosh groups, but did not change
in the AWSw group, after tracheal intubation (Fig. 4).
Arterial pressure decreased significantly in each group
after induction of anaesthesia. After tracheal intubation,
mean arterial pressure increased back to baseline levels in
all groups, and was not different between the laryngoscope
groups (Fig. 5).

Discussion
The successful tracheal intubation of a patient with limited
cervical spine movement or in whom movement of the
cervical spine is not desirable presents a significant challenge even to the most experienced anaesthetist. Cervical
spine immobilization reduces the quality of glottic
exposure, by preventing the head extension and neck
flexion necessary for optimal alignment of the three
airway axes and exposure of the vocal cords using direct

657

Malik et al.

Table 2 Intubation attempts with each device. Data are reported as mean (SD),
median (IQR), or number (%). Significantly different compared with all other
laryngoscopes P,0.05
Macintosh

Overall success rate

Max time permitted 120 s (%)
Max time permitted 60 s (%)
Duration of first intubation
attempt (s)
Duration of successful intubation
attempt (s)
Cormack and Lehane classification
Number of intubation attempts (%)
1
2
3
Number of optimization
manoeuvres (%)
0
1
2
Lowest SaO2 during intubation
attempt (%, mean, SD)
Incidence of complications
Blood on laryngoscope blade
Minor laceration
Dental or other airway trauma

AWSw

100

LMA
CTrachw

30 (100%)
30 (100%)
11 (9, 15)

30 (100%)
30 (100%)
10 (8, 15)

27 (90%)
20 (66.7%)
47 (38, 110)

11 (9, 13)

10 (8, 15)

46 (38, 107)

Heart rate

Parameter assessed

120

80
60
40
Macintosh*

2 (1, 2)

1 (1, 1)

20

Pentax AWS

LMA CTrach*

1 (1, 2)

0
29 (96.7)
1 (3.3)
0

16
13
1
98

28 (93.3)
2 (6.7)
0
24 (80)
6 (20)
0
98 (1)

(52.8)
(42.9)
(3.3)
(1)

0 (0)
2 (6.7)
0

2 (6.7)
3 (610)
0

30s Pre-Ind 30

25 (83.5)
0
5 (16.5)

14
14
2
98

(46.2)
(46.2)
(6.7)
(1)

+60
+120
Time (s)

+180

+300

Fig 4 Graph representing the changes in heart rate after tracheal

intubation with each device. The data are given as mean (SD).
*Significant change in heart rate over time within each group. 30 s
Pre-Ind, 30 s before induction of anaesthesia; 230, 30 s before tracheal
intubation; 60, 60 s post-tracheal intubation; 120, 120 s post-tracheal
intubation; 180, 180 s post-tracheal intubation; 300, 300 s
post-tracheal intubation.

0 (0)
2 (6.7)
0

Mean arterial pressure (mm Hg)

120

30

30

Macintosh

Number of patients

25

Pentax AWS
20

20

LMA CTrach
19

15
10

100
80
60
40
Macintosh*
Pentax AWS*

20

LMA CTrach*

30 s Pre-Ind 30

5
2

0
1

2
3
4
Cormack and Lehane laryngoscopy grade

Fig 3 Cormack and Lehane grade view during the first tracheal
intubation attempt with each laryngoscope. The number of patients is
shown above each bar. The distribution of Cormack and Lehane grades in
each group is significantly different (P,0.001, Kruskal Wallis ANOVA on
ranks).

laryngoscopic techniques.3 4 These manoeuvres may lead

to failure to secure the airway, which may result in substantial morbidity and even mortality.
Efforts to reduce the difficulty of tracheal intubation in
situations such as cervical immobilization have prompted
the development of a number of alternatives to the
Macintosh laryngoscope, including the AWSw11 12 and
LMA CTrachw devices.19 Recent studies, by our group
and others, have demonstrated that both the AWS10 11 and
the Airtraq,18 a similar indirect laryngoscope device that

+60
+120
Time (s)

+180

+300

Fig 5 Graph representing the changes in mean arterial pressure after

tracheal intubation with each device. The data are given as mean (SD).
*Significant change in heart rate over time within each group. 30 s
Pre-Ind, 30 s before induction of anaesthesia; 230, 30 s before tracheal
intubation; 60, 60 s post-tracheal intubation; 120, 120 s post-tracheal
intubation; 180, 180 s post-tracheal intubation; 300, 300 s
post-tracheal intubation.

also incorporates a side channel for the tracheal tube,

possess considerable advantages over the Macintosh in the
setting of cervical spine immobilization. In addition, the
AWSw laryngoscope also appears to cause less cervical
spine movements during tracheal intubation when compared with the Macintosh or McCoyw laryngoscopes.20
The efficacy of the LMA CTrachw has not been determined in this setting. Of interest, the intubating LMA
(iLMA) has demonstrated some promise in the setting of
cervical spine immobilization.21 We wished to evaluate
the relative efficacies of these novel devices when used by
anaesthetists who were familiar with the use of these

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Immobile cervical spine and laryngoscopy

indirect laryngoscopes in patients undergoing cervical

spine immobilization, and to compare these devices with
the gold standard Macintosh laryngoscope.
Our findings demonstrate that the LMA CTrachw did
not offer an advantage over the Macintosh laryngoscope
in patients undergoing cervical spine immobilization. In
fact, fewer patients were successfully intubated with the
CTrachw. This is likely to have been due to the fact that
more patients undergoing intubation with the CTrachw
had a Cormack and Lehane glottic grade 3 or 4. We
experienced considerable difficulties in obtaining an
optimal view of the glottis with the CTrachw, a problem
which has been previously reported.13 19 Furthermore,
even in patients where a good view of the glottis was
obtained, the quality of exposure was occasionally
reduced due to fogging of the lens, the presence of
secretions, and due to damage to the fibreoptics caused
by repeated sterilization of the CTrachw. Our overall
success rate of 90% in patients undergoing cervical
immobilization with the LMA CTrach, where tracheal
intubation attempts of up to 120 s were permitted, does
compare well with previous reports of a 93% success rate
with this device in normal patients.19 However, if we
limited the intubation time to 60 s, the success of tracheal
intubation decreased to 67%.
The duration of tracheal intubation attempts was significantly longer with the LMA CTrachw, a finding consistent
with previous studies.22 23 However, the clinical importance of the longer duration of tracheal intubation attempts
with the CTrach is questionable. The technique required
for tracheal intubation with the CTrach is not directly
comparable with that for the other devices tested, as it is a
two-step procedure, requiring placement of the LMA and
confirmation of effective ventilation before passage of the
tracheal tube. It must be emphasized that the LMA
CTrachw was sited correctly at the first attempt and provided effective ventilation in all patients, including those
in whom tracheal intubation was not successfully accomplished, as seen in previous studies.19 In fact, the biggest
contribution to prolonged tracheal intubation times was
not the positioning of the LMA CTrachw, but was due to
the time required to optimize the view of the glottis to
enable passage of the tracheal tube. Failure to obtain a
good view of the glottis was the reason for each failed tracheal intubation attempt with the LMA CTrachw.
In contrast, our study demonstrates that the Pentax
AWSw laryngoscope performed better than the LMA
CTrachw and the Macintosh laryngoscopes in these
patients. These findings confirm and extend our previous
findings regarding the utility of this device in patients
undergoing cervical spine immobilization.10 11 The
AWSw reduced the intubation difficulty score, enhanced
the Cormack and Lehane glottic view, and reduced the
number of optimization manoeuvres required compared
with the LMA CTrachw and the Macintosh laryngoscopes. Five patients intubated with the AWSw did

require the use of an airway intubating catheter to

facilitate tracheal intubation because of an inability to
position the view of vocal cords in the target symbol on
the monitor display, a manoeuvre which has been previously described.24 Of importance, the AWSw caused
less haemodynamic stimulation than the other laryngoscopes. Heart rate was not altered significantly with this
device during intubation attempts, in contrast to the other
devices. A blunted heart rate response to intubation has
also been previously described with the AWS10 11 and
also with the Airtraqw,18 a similar device to the AWSw.
These findings may reflect the fact that these devices
provide a view of the glottis without need to align the
oral, pharyngeal, and tracheal axes, reducing cervical
movement,20 thereby reducing the potential for haemodynamic stimulation.
An important potential advantage of the AWSw device
is that it has single-use disposable blades. This removes
concerns regarding the potential for multi-use intubation
devices to facilitate transmission of prions, which are
thought to be responsible for causing variant Creutzfeldt
Jakob disease.25 26 These concerns arise from the difficulties in ensuring that all proteinaceous material has been
removed from reusable laryngoscope blades during cleaning and sterilization.27 28 In recognition of these concerns,
the guidelines of the Association of Anaesthetists of Great
Britain and Ireland state that single use intubation aids
should be used where possible.29
Three important limitations exist regarding this study.
First, we acknowledge that the potential for bias exists, as
it is impossible to blind the anaesthetist to the device
being used. Furthermore, certain measurements used in
this study, such as laryngoscopic grading, are by their
nature subjective. In fact, the appropriateness of using the
Cormack and Lehane classification with indirect laryngoscopes, which may reduce the difficulty of obtaining a
good glottic view, but not reduce the difficulty of tracheal
intubation, is open to question. The advantage of using the
Cormack and Lehane classification is that it is well understood by clinicians, and widely used in clinical practice.
Reassuringly, there was a good agreement between subjective indices of difficulty of intubation and more objective
measures, such as the intubation difficulty score.16
Secondly, this study was carried out by experienced users
of each device. The results seen may differ in the hands of
less experienced users. Finally, the relative efficacies of
these devices in comparison with other promising devices
such as the Airtraqw,18 30 McCoyw,20 31 McGrathw,23 32
Bonfilsw33 iLMAw,21 or Bullardw21 laryngoscopes have
not been determined. Further comparative studies are
needed to determine the relative efficacies of these
devices.
In conclusion, the AWSw laryngoscope appears to
possess more advantages over the Macintosh laryngoscope
than the LMA CTrach when used by experienced anaesthetists in patients undergoing cervical immobilization.

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Malik et al.

Funding
w

Pentax Ltd provided the AWS device and disposable

blades, and Intavent Orthofix Ltd provided the LMA
CTrachw free of charge for use in the study. All other
support came from institutional, departmental, or both
sources.

Appendix: IDS score

The IDS score is the sum of the following seven variables
N1
Number of intubation attempts .1
N2
The number of operators .1
N3
The number of alternative intubation techniques used
N4
Glottic exposure (Cormack and Lehane grade minus 1)
N5
Lifting force required during laryngoscopy (0, normal;
1, increased)
N6
Necessity for external laryngeal pressure (0, not
applied; 1, applied)
N7
Position of the vocal cords at intubation (0, abduction/
not visualized; 1, adduction)

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Note: IDS score reproduced from Adnet and colleagues.16

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