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The Use of Airtraq Laryngoscope Versus Macintosh Laryngoscope and Fiberoptic Bronchoscope by Experienced Anesthesiologists

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The Use of Airtraq Laryngoscope Versus Macintosh Laryngoscope and Fiberoptic Bronchoscope by Experienced Anesthesiologists THE USE OF AIRTRAQ LARYNGOSCOPE VERSUS MACINTOSH LARYNGOSCOPE AND FIBEROPTIC BRONCHOSCOPE BY EXPERIENCED ANESTHESIOLOGISTS KEMAL T. SARACOGLU*, MURAT ACAREL**, TUMAY UMUROGLU*** AND FEVZI Y. GOGUS**** Abstract Objective: The aim was to compare the hemodynamic parameters, intubation times, upper airway trauma and postoperative sore throat scores of the patients with normal airway anatomy, intubated with the Airtraq, Macintosh laryngoscope and fiberoptic bronchoscope, by experienced anesthesiologists. Methods: Ninety patients, scheduled to undergo elective surgery under general anesthesia were randomly divided into three groups (n=30): Group A: Airtraq laryngoscope, Group M: Macintosh laryngoscope and Group FB: fiberoptic bronchoscope. The time to intubation and success rates were recorded. The hemodynamic parameters before and one minute after the anesthesia induction were recorded and the measurements were repeated 3, 4 and 5 minutes after the endotracheal intubation. The postoperative sore throat scores and signs of any trauma were also recorded. Results: Mean arterial blood pressure and heart rate were not significantly different between the three groups. The mean intubation time interval did not differ between groups. Highest postoperative sore throat scores were recorded at the 6th hour post extubation. The scores were 37.6 ± 20.9 in Group A, 13.3 ± 16.8 in Group M and 13.6 ± 14.0 in Group FB. The scores in Group A were significantly higher compared to other groups. The number of patients requiring additional analgesia to relieve sore throat was also significantly higher in GroupA. Conclusion: The Airtraq laryngoscope seems to be a more traumatic airway device in the routine endotracheal intubation compared to Macintosh laryngoscope and fiberoptic bronchoscope, when used by experienced anesthesiologists. It also does not offer advantage over the first-attempt success rates, the intubation times and hemodynamic parameters. Keywords: airway management; laryngoscope; Airtraq; Macintosh laryngoscope; fiberoptic bronchoscope; intubation. * Assistant Prof. MD. ** MD. *** Assoc. Prof. MD. **** Prof. MD. Affiliation: Department of Anesthesiology, Marmara University School of Medicine, Istanbul, Turkey. Corresponding author: Kemal Tolga SARACOGLU. Department of Anesthesiology, Marmara University School of Medicine, Fevzi Cakmak Mah. Ust Kaynarca, Pendik, Istanbul, Turkey. Tel: +902166570606, Fax: +902164144731. E-mail: [email protected] 503 M.E.J. ANESTH 22 (5), 2014 504 SARACOGLU K.T. et. al Introduction the postoperative sore throat scores and trauma to the upper airways. Recent technological advances including the light- emitting diodes, rechargeable batteries, optical systems Methods with adjustable position capability and modified laryngoscope blades allowed the development of new Following the approval of the Marmara devices such as Airtraq laryngoscope (Airtraq, Prodol University Ethics Committee, 90 patients, aged Meditec Limited, China), to facilitate and improve the between 18-65 years, with American Society of 1,2 success rate of endotracheal intubation . Although Anesthesiologists (ASA) physical status classification originally designed to facilitate difficult intubation, of 1 or 2, undergoing elective surgery under general thesee devices can also be used in the management of anesthesia and requiring endotracheal intubation 1,2 the normal airway . were included in the study. The exclusion criteria for The special design of the Airtraq allows the participation in this study were: patients with ASA 3 direct exposure of the glottic opening without the or 4, Mallampati score of 3 or 4, history of difficult necessity of optimal alignment of the oral, pharyngeal intubation, thyromental distance less than 6.5 cm, and laryngeal axes. The results of the meta-analysis sternomental distance less than 12.5 cm, body mass comparing the Airtraq with the conventional Macintosh index higher than 35 kg/m2 and limited neck mobility. laryngoscope concluded that the use of Airtraq results All patients gave their written informed consent. 3 in a rapid and accurate intubation . The Macintosh A prospective and randomised study design was laryngoscope possess a curved blade facilitating the employed and the randomisation was done with the help glottic view, reducing potential tongue and epiglottic of a random number generator downloaded from ‘http// trauma. The use of the fiberoptic bronchoscope www.random.org’9. The endotracheal intubations were (FOB, Pentax Corporation, Japan) is of great value in performed by three experienced anesthesiologists. performing endotracheal intubation, but with the main Anesthesiologists who had practiced at least 500 disadvantage for being of high cost, and the need for intubations with the Macintosh laryngoscope, 50 long practical experience. intubations with the FOB were considered as being Studies on the effectivity and complications of the ‘experienced’10. The preoperative Mallampati Airtraq and FOB are mainly conducted on manikins5-8. scores were recorded and maximum mouth opening, In these studies, the intubations are mainly performed thyromental and sternomental distances of the patients by novices or paramedics5,6. To our knowledge, were measured. All patients were premedicated with a comparison of the endotracheal intubation with 0.015 mg/kg IM atropine sulphate and 0.07 mg/kg IM Airtraq, Macintosh laryngoscope and FOB performed midazolam. The patients’ positions in the operation by the experienced anesthesiologists is lacking. room were supine with no pillow under the head. Furthermore, determination of the postoperative sore Monitoring included electrocardiogram, noninvasive throat incidence and airway trauma is not possible in blood pressure and peripheral pulse oximetry (SpO2), manikins or in simulation scenarios. end tidal carbon dioxide (ETCO2) and end tidal The purpose of this study was to compare sevoflurane concentrations. Preoxygenation was not the hemodynamic parameters, intubation times, performed. Anesthesia was induced with 5-7 mg/kg complications during and after intubation and IV thiopental sodium and 0.6 mg/kg IV rocuronium postoperative sore throat scores of the patients having bromide. The administration of the opioid analgesics normal airway anatomy, intubated with Airtraq, was not allowed in the induction period. Macintosh laryngoscope or FOB, by experienced The patients were randomly divided into three anesthesiologists. The primary outcome variables groups (n=30) and orotracheal intubated with Airtraq were the first-attempt success rate, time to successful (group A), Macintosh laryngoscope (group M) and intubation. The secondary outcome variables were the FOB (group FB). In group A, the standard inventor’s effects of the intubation on hemodynamic parameters, technique was used. Airtraq was positioned into the THE USE OF AIRTRAQ LARYNGOSCOPE VERSUS MACINTOSH LARYNGOSCOPE AND FIBEROPTIC 505 BRONCHOSCOPE BY EXPERIENCED ANESTHESIOLOGISTS vallecula and upward lifting of the epiglottis made period. At the end of 30 minutes, the sore throat scores glottic opening visible. The tube was then inserted of the patients were evaluated after direct questioning, to the trachea. In group M, direct laryngoscopy was using a 0-100 mm visual analogue scale (VAS). performed with a Macintosh blade size 3. In group FB, Postoperative sore throat VAS scores were recorded endotracheal intubation was performed with a FOB at the 6th, 12th and 24th hour. The anesthesiologist with attached tracheal tube. If a satisfactory vision evaluating the postoperative sore throat scores was was not achieved in any group, the applications of blinded to the intubation devices used. Patients having optimization maneuvers such as jaw thrust, tracheal VAS scores higher than 30 mm were administered 20 pressure, lifting, tilting or orientation of devices or mg IV meperidine hydrochloride as a rescue analgesic. the assistance of a second person were allowed and In all patients, 1 mg/kg meperidine hydrochloride IV recorded. Train-of-four (TOF) (Watch SX; Organon was given every 6 h for the first 24 h, as a postoperative Ltd Drynam Road Swords, Co. Dublin, Ireland) was used to measure the level of neuromuscular blockade. analgesia. Anesthesia was maintained with 1 MAC sevoflurane Statistical Package for Social Sciences for and %70 N2O in oxygen. Windows (SPSS) version 20.0 (SPSS Inc., Chicago, The intubation time (the time from the device IL, USA) was used for the statistical analysis. One insertion into the oral cavity and the view of the of the primary outcomes was the time to successful tube crossing the vocal cords) was measured by a tracheal intubation. Based on previously published chronometer. The intubation was failed, if it could not studies11,12, we estimated that 24 patients would be be performed less than 120 seconds. In this instance the required for each group to detect a mean difference of 6 patient was excluded from the study. Complications seconds in the overall duration of intubations, between such as esophageal intubation, upper airway mucosa groups, with a power of 80% and a significance level laceration, dental trauma or iatrogenic endotracheal (a) of 0.05. So, we enrolled 30 patients per group. cuff rupture were noted. The success or failure of Data are summarized using mean ± SD for continuous the process was also recorded. Mean arterial blood variables. Statistical comparisons between the groups pressure, heart rate, SpO and ETCO concentrations 2 2 were performed using analysis of variance
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