Beruflich Dokumente
Kultur Dokumente
doi: 10.1093/bja/aex272
Advance Access Publication Date: 14 September 2017
Respiration and the Airway
Abstract
Background. We compared the performances of the paediatric blade of a Pentax Airway Scope and an Ovassapian airway in
fibreoptic tracheal intubation in patients whose necks were stabilized by semi-rigid neck collars.
Methods. Ninety patients were enrolled in this prospective, open-label, randomized controlled trial. Patients were randomly
allocated to one of two groups (Group OVA-FOB and Group AWS-FOB). The time to tracheal intubation, success rate of tra-
cheal intubation, number of optimization manoeuvres (jaw thrust), and difficulty of manipulation of the fibreoptic broncho-
scope were compared between the groups.
Results. The time to tracheal intubation was significantly shorter (32 vs 50 s; median difference 19 s; 95% confidence interval
14–25 s; P<0.001) and manipulation of the fibreoptic bronchoscope was significantly easier for Group AWS-FOB.
Optimization manoeuvres were rarely required to facilitate fibreoptic tracheal intubation in Group AWS-FOB [jaw thrust, 0
(0%); jaw thrust with anterior neck collar removal, 1 (2%)] compared with that required in Group OVA-FOB [jaw thrust, 39
(87%); jaw thrust with anterior neck collar removal, 2 (4%)]. There was no significant difference in the success rate of tracheal
intubation on the first attempt between groups [Group AWS-FOB, 45 (100%); Group OVA-FOB, 44 (98%)].
Conclusions. Combined use of the paediatric blade of a Pentax Airway Scope and a fibreoptic bronchoscope enabled rapid
tracheal intubation, minimizing the use of external manoeuvres of the airway, in patients with limited mouth opening and
cervical spine immobilization by semi-rigid neck collars, compared with use of the Ovassapian airway and the fibreoptic
bronchoscope.
Clinical trial registration. NCT02827110.
993
994 | Kim et al.
with neck stabilization.9 LF-GP; Olympus Optical Company, Tokyo, Japan) with an outer
Recently, there have been several reports on the combined diameter of 4.1 mm was used. The paediatric blade of the
use of a fibrescope and a video laryngoscope.5 11–17 Among the Pentax-AWS was used. The acceptable outer diameter of the
various types of video laryngoscopes, the channel of the Pentax tracheal tube was 5.5–7.6 mm without a cuff.
Airway Scope (Pentax-AWS; Pentax Corporation, Tokyo, Japan) In all Group OVA-FOB participants, the Ovassapian airway
can be used for the passage of a fibrescope into the glottic inlet. was inserted before insertion of the flexible fibreoptic broncho-
However, as the channel was originally designed for a tracheal scope. In Group AWS-FOB, an anaesthetist inserted the paediat-
tube, an adult-sized blade is bulky for insertion; there is poor ric blade of the Pentax-AWS into the patient’s pharynx to obtain
manoeuvrability (multiple attempts) and a reported failure rate a laryngeal view on the video screen and held it in place. If ele-
of 17–30% with limited mouth opening.18–23 As a paediatric- vation of the epiglottis was easily obtained in a single advance-
sized blade is thinner, it would be easier to insert into the ment attempt, it was maintained while introducing the
mouth and have better manoeuvrability in a narrow oropharyn- fibreoptic bronchoscope. If the epiglottis could not be elevated
geal space than the adult-sized blade. Moreover, when com- in one attempt because the paediatric blade was too short, we
bined with the use of a fibrescope, the optimal position might did not attempt to elevate the epiglottis and instead introduced
be non-essential, thereby reducing the attempts for positioning. the fibreoptic bronchoscope through a tube channel of the pae-
We hypothesized that, in patients with semi-rigid foam neck diatric blade of the Pentax-AWS. In these instances, we main-
collars under general anaesthesia, the combined use of the pae- tained the position of the paediatric blade without applying a
diatric blade of the Pentax-AWS and a fibreoptic bronchoscope ventral (lifting) force to prevent impediment of the broncho-
would allow quicker tracheal intubation and require fewer ex- scope resulting from contact between the tip of the fibreoptic
ternal manoeuvres of the airway to facilitate intubation com- bronchoscope passing through the tube channel of the paediat-
pared with the use of an Ovassapian airway and the fibreoptic ric blade of the Pentax-AWS and the posterior portion of the
bronchoscope. tongue.
In both groups, if the fibreoptic view during advancement
was insufficient (i.e. not clear) or the advancement of the
Methods fibreoptic bronchoscope into the laryngeal inlet was difficult to
This study was a single-centre, prospective, open-label, ran- perform, jaw thrust was requested. If difficulty in the advance-
domized controlled superiority trial with two parallel groups. ment of the fibreoptic bronchoscope into the laryngeal inlet was
The study protocol was approved by the Institutional Review encountered even after jaw thrust, we removed the anterior
Board of Ajou University Hospital (Suwon, South Korea) and was portion of the neck collar and performed jaw thrust at once.
registered with ClinicalTrials.gov (NCT02827110). We recruited When the tip of the fibreoptic bronchoscope was positioned
Paediatric Pentax-AWS and fibreoptic intubation | 995
above the carina, the Ovassapian airway was kept in place, significantly reduced and modified Cormack–Lehane grade
which was our routine method, and the paediatric blade of the worsened significantly after the semi-rigid neck collar was ap-
Pentax-AWS was carefully removed from the mouth to facilitate plied. There were no significant differences in patient character-
isolation from the fibreoptic bronchoscope in the channel. The istics between the groups. In Group AWS-FOB, the epiglottis was
preloaded tracheal tube was then railroaded over the fibreoptic elevated in 14 out of 45 patients.
bronchoscope. If advancement of the tracheal tube was im- The time to tracheal intubation was significantly longer in
peded during the attempt, the tracheal tube was withdrawn Group OVA-FOB patients than in Group AWS-FOB patients (me-
over the fibreoptic bronchoscope and rotated 90 anticlockwise, dian time, 50 vs 32 s; median difference, 19 s; 95% confidence in-
then re-advanced towards the trachea. After tracheal intubation terval, 14–25 s, respectively; P<0.001). In terms of the success
was accomplished, anaesthesia was maintained with sevoflur- rate of intubation, there was no significant difference between
ane (end-tidal concentration, 1.5–2.5%) in 50% oxygen in an oxy- the groups [44 (98%) vs 45 (100%)]. One patient in Group OVA-
gen–air mixture. Appropriate blood pressure and heart rate FOB was considered as a failed tracheal intubation because it
were also maintained. took 134 s to achieve tracheal intubation. A greater number of
The time to intubation was defined as the time elapsed from optimization manoeuvres were required to facilitate fibreoptic
the opening of the mouth for insertion of the Ovassapian airway tracheal intubation in Group OVA-FOB [jaw thrust, 39 (87%); jaw
or the paediatric blade of the Pentax-AWS to the removal of the thrust with anterior neck collar removal, 2 (4%)] compared with
fibreoptic bronchoscope from the mouth after confirming the the number required in Group AWS-FOB [jaw thrust, 0 (0%), jaw
placement of the tracheal tube in the trachea. Tracheal intuba- thrust with anterior neck collar removal, 1 (2%)]. The numerical
tion was considered a failure if it was not completed within rating scale for the difficulty in manipulating the fibreoptic
120 s. If tracheal intubation failed, the method of the next tra- bronchoscope for tracheal intubation was significantly higher in
cheal intubation attempt was left to the discretion of the anaes- Group OVA-FOB compared with Group AWS-FOB (5 vs 4;
thetist in charge. Mucosal damage was defined as the presence P¼0.005). There were no differences in the incidence of mucosal
of a bloodstain in the Ovassapian airway or on the paediatric damage between the two groups.
blade of the Pentax-AWS after tracheal intubation. After these
steps, the neck collar was removed. All fibreoptic intubations
were performed by a single anaesthetist (D.H.K.), who was fa-
miliar with and had been trained in intubation using a fibreoptic
Discussion
bronchoscope. He determined the difficulty of the fibreoptic The combined use of the paediatric blade of the Pentax-AWS
bronchoscope manipulation on a numerical rating scale (0–10). and a fibreoptic bronchoscope rendered tracheal intubation
Manipulation of the Pentax-AWS was done by another anaes- quicker, with minimal use of external manoeuvres (jaw thrust)
thetist (Y.J.C.), who was familiar with the Pentax-AWS. of the airway compared with the use of the Ovassapian airway
The primary outcome of this study was the time to tracheal and the fibreoptic bronchoscope in individuals wearing semi-
intubation. A power analysis suggested that a minimum of 41 rigid neck collars under general anaesthesia.
patients in each group was required to demonstrate a difference In patients with a neck collar, the mouth opening was con-
in the time to tracheal intubation of 15 s with an SD of 24 s from a siderably reduced,1 limiting the oropharyngeal space21 and pre-
previous study25 to achieve 80% power at a 0.05 level of signifi- venting alignment of the oral, pharyngeal, and tracheal axes.3
cance. Considering a 10% dropout rate, the estimated total sam- These characteristics have been shown to contribute to the
ple size was 90. worsening of Cormack–Lehane grades by direct laryngoscopy,2
Statistical analysis was performed using SPSS version 21 thereby increasing the rate of failure of tracheal intubation.1 3 In
(SPSS Inc., Chicago, IL, USA). All analyses followed the the present study, mouth opening after application of the neck
intention-to-treat principle. Continuous data were tested for collar was significantly reduced and the modified Cormack–
normality of distribution using the Kolmogorov–Smirnov test. Lehane grade also decreased. Limited mouth opening and the
Data were presented as means with SD when normally distrib- oropharyngeal space can hamper the insertion of an adult-sized
uted and when Student’s t-test was used; non-normally distrib- blade of the Pentax-AWS into the mouth and cause injury to the
uted data were compared between groups using Mann–Whitney teeth and mouth, resulting in failure of tracheal intubation.22 23
U-tests and presented as medians with interquartile ranges. Moreover, it requires optimal positioning of the glottis in the
Categorical data were presented as numbers and percentages. centre of the video screen, prompting the anaesthetist to per-
The v2 or Fisher’s exact tests were used to compare the categori- form scooping movements, consequently resulting in multiple
cal variables between the groups. P-values <0.05 were consid- attempts.18 20 21 23 The thickness of the standard adult blade of a
ered statistically significant. The difference between groups for Pentax-AWS is 18 mm, requiring an inter-incisor gap of 25 mm
the primary outcome measure is reported with the 95% confi- for smooth manipulation of the blade.26 27 A paediatric-sized
dence interval. blade is the thinnest among the Pentax-AWS blades, and thus it
would allow for easier insertion into the mouth and better
manoeuvrability in a narrow oropharyngeal space than the
adult-sized blade. Moreover, when used in combination with a
Results fibrescope, optimal positioning might become non-essential,
Ninety-nine patients were screened for the study. Seven pa- thereby reducing attempts for positioning. Given that easy in-
tients declined to participate. Two patients were excluded be- sertion and fewer scooping movements are desirable in patients
cause of poor dentition. The participant flow diagram for the with potential cervical spine injury, the paediatric blade of the
study is presented in Figure 1. A total of 90 patients were en- Pentax-AWS was chosen to overcome these difficulties. In prac-
rolled, and all patients completed the study. There were no tice, it was easy to insert and position the tip of the paediatric
missing data in the analysis. The patient characteristics and air- blade of the Pentax-AWS into the pharynx. Moreover, the scoop-
way assessment data before and after the application of a semi- ing movement for the advancement of the paediatric blade was
rigid neck collar are shown in Table 1. Mouth opening was confined to one attempt, and fibreoptic tracheal intubation was
996 | Kim et al.
Excluded (n=9)
Not meeting inclusion crtieria (n = 2)
Declined to participate (n =7)
Other reaons (n =0)
Randomized (n=90)
Allocation
Allocated to a control group (n= 45) Allocated to a block group (n = 45)
Received allocated intervention (n=45) Received allocated intervention (n =45)
Did not receive allocated intervention (n= 0) Did not receive allocated intervention (n = 0)
Follow-Up
Analysis
feasible regardless of whether the epiglottis was elevated. There various conditions, such as the level of emergency, patient co-
was some concern that the shorter paediatric blade might im- operation, feasibility of mask ventilation, or the provider’s fa-
pinge on the posterior third of the tongue and force the tongue miliarity and experience with the procedure.28 29 One problem
backwards towards the oropharynx, thereby impeding the bron- with fibreoptic orotracheal intubation under general anaesthe-
choscopy, but there were no such issues when the paediatric sia is that the loss of pharyngeal muscle tone reduces the oro-
blade of the Pentax-AWS was used. The combined use of the pharyngeal space for the passage of the fibreoptic bronchoscope
paediatric blade of the Pentax-AWS and a fibreoptic broncho- and makes it difficult to maintain the fibreoptic bronchoscope
scope was a feasible option in patients with limited mouth in the midline while advancing its tip into the pharynx and the
opening. laryngeal inlet.5–7 Consequently, specific oral airway or addi-
In patients wearing neck collars because of potential cervical tional manoeuvres to open the pharyngeal airway are com-
spine injuries, an alternative method is required instead of con- monly required.7 9 In the present study, while applying the
ventional direct laryngoscopy.3 The optimal method for guaran- Ovassapian airway, the fibreoptic view was frequently ob-
teeing a high success rate of intubation while minimizing structed and identification of the midline was difficult. Only
cervical spine movement remains under debate.1 In addition to when jaw thrust was applied in 91% of the patients of Group
being a reliable method, fibreoptic tracheal intubation might be OVA-FOB was a laryngeal view obtained. On the contrary, in all
a good alternative for minimizing cervical spine movements.4 patients of Group AWS-FOB, the midline was easily identified
Although awake fibreoptic tracheal intubation is the most reli- because the epiglottis or laryngeal inlet was obtained on the
able method, fibreoptic tracheal intubation can also be per- screen of the Pentax-AWS without additional manoeuvres (e.g.
formed under general anaesthesia upon consideration of jaw thrust), and the gel-coated fibreoptic bronchoscope could be
Paediatric Pentax-AWS and fibreoptic intubation | 997
Revising the manuscript: D.H.K., J.Y.Y., S.Y.H., Y.J.C.. alone for tracheal intubation: a manikin study. J Anesth 2011;
25: 93–7
16. Sharma D, Kim LJ, Ghodke B. Successful airway management
Declaration of interest R
with combined use of GlidescopeV videolaryngoscope and
None declared. fiberoptic bronchoscope in a patient with Cowden syn-
drome. Anesthesiology 2010; 113: 253–5
R
17. Zhang S, Yi M. AirtraqV laryngoscope-assisted fiberoptic
Funding bronchoscope intubation in a child with Pierre-Robin se-
This research received no specific grants from any funding quence: a case report. Int J Clin Exp Med 2015; 8: 6372–3
agencies in the public, commercial, or not-for-profit sectors. 18. Kim JK, Kim JA, Kim CS, Ahn HJ, Yang MK, Choi SJ.
Comparison of tracheal intubation with the Airway Scope or
Clarus Video System in patients with cervical collars.
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