airway management data show by alaa holiel summary

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airway management data show by alaa holiel summary

  1. 1. Airway management : Comparative study between McGrath VL and Airtraq OL VS Macintosh laryngoscope in neutral neck position
  2. 2. Presented by Alaa Elsayed Goma Falogy M.Sc. of Anaesthesia and surgical intensive care Faculty of medicine Zagazig university 2016
  3. 3. Under supervision of Prof; Ayman Abdel El-Salam Hassan Professor of Anesthesia and surgical Intensive Care Prof; Ahmed Abd El-Hakim Balata Professor of Anesthesia and surgical Intensive Care Prof; Khaled Mohammed El-Sayed Professor of Anesthesia and surgical Intensive Care
  4. 4. Research question If used by [experienced anesthiologists] managing a model of a difficult airway in form of neck immobilization by semi- rigid neck collar Do [ the Airtraq OL and the McGrath VL] Are [more safe and more effective in tracheal intubation ] when compared to [Classic Macintosh laryngoscope]?
  5. 5. Introductio n
  6. 6. INTRODUCTION: • Airway management is a major challenge for the anaesthesiologists in their everyday operative practice using direct laryngoscopy. • During this direct laryngoscopy, positioning of the head and neck in NEUTRAL POSITION will decrease chance of optimal laryngeal visualization which impair the line of sight between laryngeal , pharyngeal and oral axes.
  7. 7. Concept of line of sight during direct laryngoscopy :
  8. 8. INTRODUCTION: • patients with cervical spine instability who necessitate neck immobilization , airway management implies upon a high risk of neurological damage related to head and neck manipulation, so semi-rigid neck collar is applied in trail to control neck movement. • Such immobilisation technique can turn intubation process under the direct laryngoscopy into more difficult situation (Impair the line of sight) . INTRODUCTION:
  9. 9. INTRODUCTION: • These concerns have aroused the idea to develop number of alternatives to classical Macintosh laryngoscope such as Airtraq ® OL, McGrath® Video laryngoscope. • These laryngoscopes do not require the arrangement of pharyngeal, laryngeal and oral axis in one line of sight and thus do not require modulation of neutral position. • During difficult airway situations, both Airtraq optical laryngoscope and McGrath Video laryngoscope sound to be better than Macintosh laryngoscope
  10. 10. in stimulated difficult intubation situations in patients with their cervical spine kept in neutral position by semi-rigid neck collar as an immobilization techniques. VS
  11. 11. NECK EXTENSION
  12. 12. Cervical spine stability:  Cervical Stability:  is the ability of the spine to maintain strong relationships between vertebrae, so as not to damage the neural structures contained within the spinal column Cervical instability: Excess translational or rotational motion of any vertebra and means that the odontoid process is no longer firmly held against the back of the anterior arch of C1.
  13. 13. Concept of Videolaryngoscopy: Video laryngoscopy (VL) is an update of high resolution micro-cameras systems that improves the success rate of intubation.  There is a hypothesis that improved lighting and a better view can increase the chance of intubation success.  Anaesthesia had used the miniature camera for many years but for only bronchial endoscopy .
  14. 14. Video Laryngoscopy in difficult Airway management :
  15. 15. McGrath Video- Laryngoscope
  16. 16. The McGrath Video Laryngoscope: (Aircraft Medical, Edinburgh, United Kingdom) • A video-based system for tracheal intubation that utilizes a video camera embedded into a camera stick. • The unit is a battery powered Features a single electronic control • Offers the user an image of the Glottis and the surrounding anatomy on a LCD screen. • The unit which is used as a part of much the same way as common as Macintosh laryngoscope
  17. 17. Concept of the improved glottic view Based upon the hypothesis that improved glottic view leads the better chance of successful intubation
  18. 18. AIRTRAQ Optical Laryngoscope
  19. 19. AIRTRAQ Optical Laryngoscope  based on refraction prism principle to give an angular view of the glottic area.  The blade of the Airtraq consists of two side by side channels.  One channel act as housing for the ETT, and the other channel terminates in terminal lenses and transmit back the image.  The viewed image is then been transmitted to a proximal eye piece viewfinder employing a prisms system and lenses not as basic concepts of usual fiberoptics.
  20. 20. PATIENTS AND METHODS
  21. 21. METHODOLOGY  This was a prospective, randomized clinical trial.  group assignments (C, A and M)  age group of 20-50 years, ASAps Grades I or II undergoing elective surgery requiring general Anaesthesia  three groups of 50 patients each , of either sex.  All patients will receive standard monitoring according to ASA guidelines.
  22. 22. INTUBATION PROCEDURE  Intubation process was performed by one anesthesiologist with accepted experience in two recent video laryngoscopes under study.  A malleable stylet was used in both groups (Classical Macintosh and McGrath VL).  The technique was considered failed if tracheal intubation was not achieved within 120 seconds or within a maximum of three intubation attempts.
  23. 23. CORMACK & LEHANE SCORE
  24. 24. INTUBATION PROCEDURE  Intubation time was separated into T1 and T2. T1 is the time between insertions of the allocated laryngoscope in the mouth until optimal glottic view including optimization maneuvers. T2 is the time from optimal glottic view till confirmation of tracheal intubation (by vision) including removal of the device.
  25. 25. McGrath VL; INTUBATION TECHNIQUES AND SEQUENCE
  26. 26. Intubation sequence by McGrath VL  With the patient in neutral position, Use left hand to introduce the VL into the midline of the oropharynx.  Push the blade tip till it past the posterior portion of the tongue.  Now, move eyes to the video screen in order to obtain the best view of the glottis.  The video image of the glottis now is representing Cormack – Lehane view.  Using video visualization, the ETT is then advanced on a smooth curve through the glottis mediated by styllet.
  27. 27. Intubation sequence by McGrath VL
  28. 28. Intubation sequence by McGrath VL
  29. 29. Intubation sequence by McGrath VL
  30. 30. AIRTRAQ OL; INTUBATION TECHNIQUES AND SEQUENCE
  31. 31. Intubation sequence by Airtraq OL  Add lubricant to outer surface of the endotracheal tube and hosting channel of Airtraq OL.  Embed the tube into the side holding channel of the Airtraq so that the tip of the endotracheal tube is at the tip of the side channel.  Turn on the light for about 30-60 seconds before the procedure.
  32. 32. Intubation sequence by Airtraq OL  Hold the device in the mouth in the midline by right hand .  advance by sliding the device over the tongue.  check the image on view finder to optimize the view by moving the blade as necessary by left hand.  Be sure that the laryngeal inlet is in the centre of viewfinder just before pushing the ETT forward by right hand .
  33. 33. Intubation sequence by Airtraq OL
  34. 34. Intubation sequence by Airtraq OL
  35. 35. Intubation sequence by Airtraq OL
  36. 36. RESULTS OF THE STUDY
  37. 37. COMPARISON BETWEEN GROUPS ARE DONE ACCORDING TO:  INTUBATION CONDITIONS  NUMBERS OF ATTEMPTS  Optimization Procedures  Cormack and Lehane score  IDS  SUCCESS RATE OF INTUBATION  TIME TO INTUBATION  HEMODYNAMICS  COMPLICATIONS
  38. 38. DEMOGRAPHIC AND AIRWAY ASSESSMENT DATA Demographic data Group C Group A Group M p-value (Sig.) (N=50) (N=50) (N=50) Age (in years) 35.90±7.65 35.92±7.70 35.16±7.72 0.856** (NS) Male / Female 62 / 38 % 66 / 34 % 60 / 40 % 0.892* (NS) Height (cm) 171.48±3.71 171.62±3.54 171.6±3.8 0.981** (NS) Weight (Kg) 77.96±7.22 77.62±6.25 76.86±6.93 0.619** (NS) BMI (Kg/m2 ) 26.84±2.29 27.06±2.05 26.14±2.13 0.095** (NS) ASAps I / II 14 / 86 % 16 / 84 % 10/ 90 % 0.668* (NS) MS I / II 56 / 44 % 48 / 52 % 62 / 38 % 0.369* (NS) TMD (cm) 7.18±0.34 7.12±0.34 7.17±0.32 0.766** (NS)
  39. 39. DEMOGRAPHIC AND AIRWAY ASSESSMENT DATA Non-Significant
  40. 40. RESULTS OF THE STUDY numbers of attempts Macintosh group Airtraq group McGrath group HS
  41. 41. RESULTS OF THE STUDY Cormack-Lehane score in each group 43 Airtraq almost get C&L I MacintoshleastinC&LI Most views of McGrath C&L II Macintosh most C&L II HIGHLY- SIGNIFICANT
  42. 42. RESULTS OF THE STUDY IDS DISTRIBUTION AirtraqendinIDS2 McGrathendsinIDS4 MacintoshendsinIDS7 HIGHLY- SIGNIFICANT
  43. 43. RESULTS OF THE STUDY SUCCESSFULNESS 45 Macintoshhas4failures NON- SIGNIFICANT
  44. 44. RESULTS OF THE STUDY SUCCESSFULNESS FAMILARITY & ADAPTATION
  45. 45. Post-hoc inter-group analysis 47 BETTER IMAGE CONCEPT THOERY SAME VIDEOSCOPE EFFIENCY FAMILARITYNO NEED FOR ALIGNMENT
  46. 46. AIRTRAQ LEAST MACINTOSH MOST
  47. 47. When it comes to intubation time? 50 Again..Familiarity
  48. 48. RESULTS OF THE STUDY Complications Occurrence Sharp tip for both devices produce more trauma as primary insult more than secondary injury Stylet manipulation
  49. 49. LIMITATIONS DESIGN operator knows the devices, which may also introduce bias. (solved by closed envelopes basis). STIMULATIVE not on real cervical trauma patients. FURTHERMORE……… inter-incisor distance may be added in airway assessment parameters as pre and post insertion of neck collar especially because it affects primary insertion of Airtraq OL.
  50. 50. SUMMARY AND CONCLUSION
  51. 51. The conclusion of this study proves that Airtraq OL and McGrath VL are: MORE EFFECTIVE AND SAFE Than Macintosh Laryngoscope in managing stimulated difficult intubation situation in form of cervical spine immobilization by semi-rigid neck collar
  52. 52. RECOMMENDATIONS
  53. 53. This study recommends use of videolaryngoscopes in our daily practice specially in difficult airway scenarios such as neck immobilization situations because it provide better airway management even without extensive training, and it is needed to conduct similar studies upon real cervical trauma patients for better assessment of its advantages and disadvantages.
  54. 54. I would like to thank…. Prof, Dr.: Salah A. Fattah Ismail For his sincere effort to travel all this distance to give us this honor to be with us this special day
  55. 55. I would like to thank…. Prof, Dr.: Ahmed M. Salama For his pleased acceptance to share us this discussion
  56. 56. I would like to thank…. My family that suffered a lot through all this period of Ph.D. journey And they deserve all love and care
  57. 57. THANK YOU

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