Impact of two different head and neck alignment planes on glottic visualization at laryngoscopy in adults
DOI:
https://doi.org/10.18203/2349-3933.ijam20251076Keywords:
Glottic view, head-neck alignment planes, laryngoscopyAbstract
Background: Optimal head and neck positioning is key to rapid, successful tracheal intubation enabling circumvention of peri-intubation sequelae; thus, scientific search for definite anatomical landmarks to serve as reference points for favorable head and neck alignment during laryngoscopy is warranted.
Methods: Ethical approval obtained, 78 adults aged 18-60 years, of American society of anesthesiologists (ASA) class I and II, were randomized into groups A and B, of 39 each. All patients had general anaesthesia with oro-tracheal intubation. Group A had the suprasternal notch and external auditory meatus (SN-EAM) plane aligned horizontally, while group B had the sternal angle of Louis and external auditory meatus (SAL-EAM) plane horizontally aligned, for direct laryngoscopy. Glottic view achieved and external laryngeal manoeuvre with backward, upward, rightward pressure (BURP) application was assessed using Cormack-Lehane grading and four-point Likert scale respectively; intubation attempts, immediate post-intubation arterial oxygen saturation (SpO2), and time to orotracheal intubation (TTOTI) defined as the period from removal of preoxygenating face mask to first capnographic evidence of correct tracheal intubation, were recorded.
Results: All 78 subjects completed the study. Groups A and B were similar in degree of glottic visualization (p=0.642) and TTOTI (33.38±5.09 versus 33.18±5.77, p=0.868); tracheal intubation attempts, BURP application and immediate post-intubation SpO2 (98.25±0.72 versus 98.23±0.81, p=0.833) were also comparable.
Conclusion: Aligning the SN-EAM plane horizontally achieved degree of glottic visualization comparable to keeping horizontally the SAL-EAM plane, during direct laryngoscopy in adults.
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References
Fiadjoe JE, Nishisaki A, Jagannathan N, Hunyady AI, Greenberg RS, Reynolds PI. Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis. Lancet Respiratory Med. 2016;4(1):37-48. DOI: https://doi.org/10.1016/S2213-2600(15)00508-1
Collins SR. Direct and Indirect Laryngoscopy: Equipment and Techniques. Respiratory Care. 2014;59(6):850-64. DOI: https://doi.org/10.4187/respcare.03033
Nur HAH, Choy CY. Comparison of the 'sniffing the morning air' position and simple head extension for glottic visualisation during direct laryngoscopy. Middle East J Anaesthesiol. 2014;22(4):399-405.
Hasegawa K, Shigemitsu K, Hagiwara Y, Chiba T, Watase H, Brown CA. Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. Ann Emerg Med. 2012;60(6):749-54. DOI: https://doi.org/10.1016/j.annemergmed.2012.04.005
Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg. 2004;99(2):607-13. DOI: https://doi.org/10.1213/01.ANE.0000122825.04923.15
Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of first-pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med. 2013;20(1):71-8. DOI: https://doi.org/10.1111/acem.12055
Greenland KB, Eley V, Edwards MJ, Allen P, Irwin MG. The origins of the sniffing position and the Three Axes Alignment Theory for direct laryngoscopy. Anaesth Intensive Care. 2008;36(1):23-7. DOI: https://doi.org/10.1177/0310057X0803601s05
Akhtar M, Ali Z, Hassan N, Mehdi S, Wani GM, Mir AH. A Randomized Study Comparing the Sniffing Position with Simple Head Extension for Glottis Visualization and Difficulty in Intubation during Direct Laryngoscopy. Anesthesia Essays Res. 2017;11(3):762-6. DOI: https://doi.org/10.4103/0259-1162.204206
Greenland KB, Edwards MJ, Hutton NJ. External auditory meatus-sternal notch relationship in adults in the sniffing position: a magnetic resonance imaging study. Br J Anaesth. 2010;104:268-9. DOI: https://doi.org/10.1093/bja/aep390
Katz DL, Jekel JF, Elmore JG, Wild DMG, Lucan SC. Sample size calculation for epidemiological studies. In: Jekel JF Editor. Jekel’s Epidemiology, Biostatistics, Preventive Medicine and Public Health. 4th edition. Philadelphia. Saunders, Elsevier Inc. 2014;155-70.
Chun EH, Chung MH, Kim JE, Kim JM, Lee HS, Son JM, et al. Effects of head-elevated position on tracheal intubation using a McGrath MAC videolaryngoscope in patients with a simulated difficult airway: a prospective randomized cross-over study. BMC Anesthesiol. 2022;22:166-76. DOI: https://doi.org/10.1186/s12871-022-01706-5
Rensis L. A Technique for the Measurement of Attitudes. Arch Psychol. 1932;140:1-55.
Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia. 1984;39(11):1105-11. DOI: https://doi.org/10.1111/j.1365-2044.1984.tb08932.x
Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society Guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004;59(7):675-94. DOI: https://doi.org/10.1111/j.1365-2044.2004.03831.x
Traylor BA, McCutchan A. Unanticipated Difficult Intubation in an Adult Patient. In: StatPearls (Internet). Treasure Island (FL): StatPearls Publishing; 2024.
Goto T, Gibo K, Hagiwata Y, Morita H, Brown DF, Brown CA, et al. Multiple failed intubation attempts are associated with decreased success rates on the first rescue intubation in the emergency department: a retrospective study of multicentre observational data. Scand J Trauma Resusc Emerg Med. 2015;23:5. DOI: https://doi.org/10.1186/s13049-014-0085-8
Cook TM, MacDougall-Davies SR. Complications and failure of airway management. Br J Anaesth. 2012;109(1):i68-85. DOI: https://doi.org/10.1093/bja/aes393
Knill RL. Difficult laryngoscopy made easy with a BURP. Can J Anaesth. 1993;40(3):279-82. DOI: https://doi.org/10.1007/BF03037041
Takahata O, Kubota M, Mamiya K, Akama Y, Nozaka T, Matsumoto H, et al. The efficacy of the “BURP’ maneuver during a difficult laryngoscopy. Anesth Analg. 1997;84:419-21. DOI: https://doi.org/10.1097/00000539-199702000-00033
Oh S, Heo S, Cheon S-U, Ryu S-A. The effects of backward, upward, rightward, pressure maneuver for intubation using the OptiscopeTM: a retrospective study. Anesth Pain Med. 2021;16:391-7. DOI: https://doi.org/10.17085/apm.21026
Yu T, Wu RR, Longhini F, Wang B, Wang MF, Yang FF, et al. The “BURP” maneuver improves the glottis view during laryngoscopy but remains a difficult procedure. J Int Med Res. 2020;48(5):300060520925325. DOI: https://doi.org/10.1177/0300060520925325
Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012;59(3):165-75. DOI: https://doi.org/10.1016/j.annemergmed.2011.10.002
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