International Journal of Advanced and Integrated Medical Sciences

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Comparative Evaluation of Performance ofVideolaryngoscope vs Fastrach IntubatingLaryngeal Mask Airway
  IJAIMS
ORIGINAL ARTICLE
Comparative Evaluation of Performance ofVideolaryngoscope vs Fastrach IntubatingLaryngeal Mask Airway
1Siddhartha Hanjura, 2Anil P Agrawal, 3Malti Agrawal, 4Vartika Singh, 5Vartika Vinay, 6Reehan Ahmed
1,5,6Junior Resident, 2Associate Professor, 3Professor and Head
4Assistant Professor
1,3-6Department of Anesthesiology, Rohilkhand MedicalCollege & Hospital, Bareilly, Uttar Pradesh, India
2Department of Orthopedics, Rohilkhand Medical College &Hospital, Bareilly, Uttar Pradesh, India
Corresponding Author:
Siddhartha Hanjura, Junior ResidentDepartment of Anesthesiology, Rohilkhand Medical College &Hospital, Bareilly, Uttar Pradesh, India,
Phone: +919469220220
e-mail: siddharthahanjura@gmail.com
10.5005/jp-journals-10050-10064
 
ABSTRACT
Introduction: This prospective randomized study aimed tocompare the effectiveness of the intubating laryngeal maskairway (ILMA) with the King Vision Video laryngoscope in aidingendotracheal intubation in Asian patients with normal airway.King Vision Video laryngoscope is a two-piece design. It has areusable monitor that attaches to disposable blades. The ILMAis a device specifically designed to be an effective ventilatorydevice and blind intubating guide in patients with normal andabnormal airways.
Materials and methods: After ethics committee approvaland obtaining patient's written informed consent, 60 AmericanSociety of Anesthesiologists grade I and II adult patientsundergoing elective surgery requiring intubation were randomlyallocated into either the ILMA group (Group L) or the King VisionVideo laryngoscope group (Group V).
  • Thorough preanesthetic checkup was done. Patient waspremedicated. Induction was done with propofol 2.5 mg/kg and succinylcholine 1.5 mg/kg. In Group L, ILMA wasinserted using a single-handed rotational technique. In theKing Vision Video laryngoscope group, intubation was donewith videolaryngoscope. Placement was confirmed withauscultation and capnography.
  • An independent observer recorded the following:
    - Time taken for successful intubation
    - Success or failure of the tracheal intubation
    - Number of attempts needed for successful trachealintubation
    - Complication associated with tracheal intubation: bleedingor postoperative sore throat
    - Hemodynamic response to intubation
Results and conclusion: King Vision Video laryngoscope isthe more effective technique in aiding endotracheal intubationin patients with normal airways
Keywords: Intubating laryngeal mask airway, Intubation, KingVision video laryngoscope.
How to cite this article: Hanjura S, Agrawal AP, Agrawal M,Singh V, Vinay V, Ahmed R. Comparative Evaluation ofPerformance of Videolaryngoscope vs Fastrach IntubatingLaryngeal Mask Airway. Int J Adv Integ Med Sci 2017;2(1):1-7.
Source of Support: Nil
Conflicts of Interest: None
 
 

 
INTRODUCTION

King Vision has been designed with the intention to makea revolutionary series of high-performance portable videolaryngoscopes.The King Vision combines the convenienceof a durable, reusable video display with a disposable blade.

The King Vision Video laryngoscope is a two-piecedesign. It has a reusable monitor that attaches to disposableblades. In some respects, this is a similar approach tothe Pentax Airway Scope, which has a reusable monitorand disposable blades. This makes the design simpler touse as one essentially just has to connect the two piecestogether by simply sliding them into each other.

The blades are all Macintosh #3 size and comparedwith a normal Macintosh #3 bladed laryngoscope, the KingVision blades appear wider and shorter. There are bladeswith a guiding channel and standard blades without. Bothonly come in #3 size though. The guide channel blade isvery similar to the Pentax and Airtraq blade designs.

The display is an organic light-emitting diode designof surprisingly good clarity and resolution. It is turned onwith a single power button on the back of the display andturned off by depressing it for 3 seconds. It is certainly ano-frills design, which makes it simple to understand anduse. There is no brightness adjustment nor in-built videorecording function. There is a mini universal serial busport for a video out function to either a display or digitalrecorder. The LED light on the blade tip is very good withexcellent intensity and a pale white illumination. Thedevice is powered by standard AAA size batteries × 3and is rated to last at least 90 minutes or greater.

The intubating laryngeal mask airway (ILMA) is adevice specifically designed to be an effective ventilatorydevice and blind intubating guide in patients with normaland abnormal airways. The principal features of ILMA arean anatomically curved, rigid airway tube with an integralguiding handle, an epiglottic elevating bar replacing theLMA bars, and a guiding ramp to direct the tracheal tubeanteriorly as it emerges from the mask aperture.

This prospective randomized study aimed tocompare the effectiveness of the ILMA technique withthe King Vision Video laryngoscope in aiding endotrachealintubation in Asian patients with normal airways.As airway management is routine in anesthesia practice,the option and availability of a reliable tool to secure theairway other than direct laryngoscopy is important todecrease morbidity in difficult airway situations. Thistrial comparing the ILMA and the King Vision Videolaryngoscope allows an anesthesiologist proficient inboth devices to select the most effective device in anticipatedand unanticipated difficult airways.

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MATERIALS AND METHODS

After Ethics Committee approval and obtaining patients'written informed consent, 60 American Society ofAnesthesiologists (ASA) grade I and II adult patientsundergoing elective surgery requiring intubation wererandomly allocated into either the ILMA group (Group L)or the King Vision Video laryngoscope group (Group V).Exclusion criteria were patients with difficult airways(defined as patients with a history of impossible intubation,mouth opening less than 20 mm, cervical spinefixed in flexion, Mallampati class III or IV, thyromentaldistance less than 65 mm), ASA grade III, IV, or V, thosewith respiratory tract pathology or coagulation disorders,or those at risk of regurgitation-aspiration (previousgastrointestinal surgery, known hiatus hernia, esophagealreflux, peptic ulceration, or not fasted). Randomizationwas performed using sealed opaque envelops.

Thorough preanesthetic checkup was done andinformed written consent was taken. Tab Ranitidine150 mg and alprazolam 0.25 mg were given orally thenight before surgery.

Patient was premedicated with Inj. ranitidine 50 mg,Inj. ondansetron 4 mg, Inj. glycopyrrolate 0.2 mg, andInj. butorphanol 1 mg. Induction was done with propofol2.5 mg/kg and succinylcholine 1.5 mg/kg. Beforeinduction, preoxygenation was performed in all cases (4minutes by bag and mask with 100% oxygen). Each patientwas routinely monitored during the entire procedure byelectrocardiography, peripheral capillary oxygen saturation,partial pressure or maximal concentration of carbondioxide, and noninvasive blood pressure measurements.

In the ILMA group, ILMA was inserted using a singlehandedrotational technique. If resistance was felt duringbag ventilation or if the tracheal intubation had failed,following adjusting maneuvers were performed: (1)Performing an up and down maneuver to prevent theepiglottis from downfolding, by swinging the ILMA backoutward a few centimeters without deflating the cuff andthen repositioning the ILMA; (2) optimizing the airwayby steering the ILMA with the handle and moving it inthe horizontal plane from one side to the other or raisingthe mask upward, while squeezing the reservoir bag toobtain the lowest resistance during insufflations anda complete expiration; and (3) removing the ILMA tochange its size. Initial size selection for the ILMA was asfollows: Size 3 for patients less than 50 kg and size 4 forthose greater than 50 kg. However, the anesthesiologistwas permitted to change the size during the study (Fig. 1).

 
The cuff was inflated with air (size 3, 20 mL; size 4,30 mL) and an anesthesia circuit was connected. The positionof the ILMA was adjusted until optimal ventilationwas obtained. This position was maintained by holdingthe handle firmly. The tracheal tube was inserted throughthe ILMA and advanced to 9 cm beyond the epiglotticelevating bar if no resistance was felt. If resistance wasfelt through the tracheal tube, the ILMA was readjustedin the patient's mouth before the second attempt of trachealtube insertion. If tracheal intubation was unsuccessfulin second attempt, the following adjusting maneuverswere performed before a further attempt depending onthe depth of resistance: 1.5 to 2.0 cm, withdrawal of theILMA by 5 cm followed by reinsertion; 0 to 1.5 or >4 cm,a smaller size ILMA is used; and 2 to 4 cm, a larger sizeILMA is used. In the ILMA group, ventilation using theILMA was permitted between attempts, if required.

In the King Vision Video laryngoscope group, theanesthesiologist introduced the blade along the middleof the tongue. The glottis opening was observed onthe liquid crystal display (LCD) screen by advancingthe blade down the posterior pharynx while followingthe path of advancement on the LCD screen. A 7 mminternal diameter endotracheal tube was introduced inthe slit, which is present on the blade of videolaryngoscope,and the patient was intubated. Placement wasconfirmed with auscultation and capnography. If theanesthesiologist failed to introduce the endotrachealtube through the glottic opening, the following maneuverswere used to aid tracheal intubation: Externallaryngeal pressure, withdrawal and readjustment ofthe endotracheal tube, increase the lifting force ofintubating device, or slight withdrawal of intubatingdevice.

Comparative Evaluation of Performance of Videolaryngoscope vs Fastrach Intubating Laryngeal Mask Airway
Fig. 1: Intubation with video laryngoscope and fastrach ILMA

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Comparative Evaluation of Performance of Videolaryngoscope vs Fastrach Intubating LMA

An independent observer recorded the following:
  • Time taken for successful intubation
  • Success or failure of the tracheal intubation
  • Number of attempts needed for successful trachealintubation
  • Complication associated with tracheal intubation:bleeding or postoperative sore throat
  • Hemodynamic response to intubation

The anesthesiologist was allowed three attempts orup to 120 seconds to intubate the trachea successfully.More than three attempts or 120 seconds was regardedas failure of intubation. Failure to secure the airwaywith either technique resulted in the use of directlaryngoscope to secure the airway. Patients with failedintubation were not included in the analysis of the totalintubation time.

 
STATISTICS

Data were summarized as mean ± standard deviationor as percentages. Statistical analysis was performedby Statistical Package for the Social Sciences version15. Numerical variables were normally distributed andcompared by Student's unpaired "t"-test.

RESULTS

All the patients (n = 60) completed the study.

There was no significant difference in age, weight,height, body mass index (BMI), ASA, Mallampati grade,mouth opening, thyromental distance, and neck circumferencein both the groups (Table 1 and Graphs 1 to 5).

Mean tracheal intubation time (seconds) in Group Vwas 24.6 ± 2.00 seconds, and it was 37.42 ± 2.46 seconds inGroup L (Table 2 and Graphs 6 to 10). There was a highlysignificant difference in tracheal intubation time (seconds)in both groups. Tracheal intubation was successful in all 30patients in the first attempt in Group V and 24 patients infirst attempt and 4 patients in second attempt in Group L.There was significant difference in successful trachealintubation in both groups. There were no failed intubationsin any of the patients in Group V and in two patientsin Group L. There was no significant difference in systolicblood pressure (SBP) and diastolic BP (DBP) and heart rateat different time intervals in both groups.


Table 1: Patient and airway profile
Comparative Evaluation of Performance of Videolaryngoscope vs Fastrach Intubating Laryngeal Mask Airway


Comparative Evaluation of Performance of Videolaryngoscope vs Fastrach Intubating Laryngeal Mask Airway
Graph 1: Mean age in Groups V and L

 
Comparative Evaluation of Performance of Videolaryngoscope vs Fastrach Intubating Laryngeal Mask Airway
Graph 2: ASA grades in Groups V and L

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Comparative Evaluation of Performance of Videolaryngoscope vs Fastrach Intubating Laryngeal Mask Airway
Graph 3: Mallampati class in Groups V and L

Comparative Evaluation of Performance of Videolaryngoscope vs Fastrach Intubating Laryngeal Mask Airway
Graph 5: Mean neck circumference in Groups V and L

 
Comparative Evaluation of Performance of Videolaryngoscope vs Fastrach Intubating Laryngeal Mask Airway
Graph 4: Mouth opening in Groups V and L

There were no complications in patients in Group V,and three patients had bleeding (orotracheal) and threepatients had sore throat in Group L (Table 3).

DISCUSSION

We showed that the videolaryngoscope was easier toinsert and significantly shortened the time for successfulintubation. The improvement of intubation timeof 24.6 ± 2 seconds seen with the King Vision Videolaryngoscope may be clinically significant in influencingthe choice of airway adjuncts for use in patients withdifficult airways, in which the instrument that allows afaster intubating time will decrease the apnoeic period,reducing the risk of hypoxia in difficult intubations.


Table 2: Observations
Comparative Evaluation of Performance of Videolaryngoscope vs Fastrach Intubating Laryngeal Mask Airway

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Comparative Evaluation of Performance of Videolaryngoscope vs Fastrach Intubating LMA

Comparative Evaluation of Performance of Videolaryngoscope vs Fastrach Intubating Laryngeal Mask Airway
Graph 6: Mean tracheal intubation time inGroups V and L

Comparative Evaluation of Performance of Videolaryngoscope vs Fastrach Intubating Laryngeal Mask Airway
Graph 8: Mean SBP in Groups V and L

Comparative Evaluation of Performance of Videolaryngoscope vs Fastrach Intubating Laryngeal Mask Airway
Graph 10: Mean HR in Groups V and L

 
Comparative Evaluation of Performance of Videolaryngoscope vs Fastrach Intubating Laryngeal Mask Airway
Graph 7: Successful tracheal intubation in Groups V and L

Comparative Evaluation of Performance of Videolaryngoscope vs Fastrach Intubating Laryngeal Mask Airway
Graph 9: Mean DBP in Groups V and L

Table 3: Complication
Comparative Evaluation of Performance of Videolaryngoscope vs Fastrach Intubating Laryngeal Mask Airway

Mean age in Group V was 35.57 ± 5.30 years and itwas 35.57 ± 5.30 years in Group L. There was no significantdifference in age in both the groups. Mean weightin Group V was 62.73 ± 4.49 kg and it was 62.63 ± 4.75 kgin Group L. There was no significant difference inweight in both groups. Mean height in Group V was156.83 ± 9.33 cm and it was 158.27 ± 3.81 cm in Group L.There was no significant difference in height in bothgroups. Mean BMI in Group V was 25.75 ± 3.88 kg/m2and it was 25.01 ± 1.86 kg/m2 in Group L. There was nosignificant difference in BMI in both groups. There were17 patients in ASA I and 13 in ASA II in both groups,and there was no significant difference in ASA in bothgroups. There were 17 patients in Mallampati class Iand 13 in Mallampati class II in Group V and 16 patientsin Mallampati class I and 14 in Mallampati class II inGroup L, and there was no significant difference inMallampati class in both groups. Mean mouth openingin Group V was 5.05 ± 0.23 cm and it was 5.06 ± 0.23 cmin Group L. There was no significant difference in mouthopening in both groups. Mean thyromental distance inGroup V was 7.42 ± 0.20 cm and it was 7.38 ± 0.16 cmin Group L. There was no significant difference inthyromental distance in both groups. Mean neck circumferencein Group V was 34.35 ± 1.09 cm and it was34.74 ± 1.16 cm in Group L. There was no significantdifference in neck circumference in both groups.

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Time taken for tracheal intubation was muchless in Group V than in Group L. All the patients inGroup V were successfully intubated in first attempt,whereas 24 patients were successfully intubated inthe first attempt, four patients in second attempt, andin two patients intubation through ILMA was unsuccessful.The mean SBP at 0 minute in Group V was131.37 ± 5.05 mm Hg, at 2.5 minutes 113.0 ± 6.57 mm Hg,and at 5 minutes 113.20 ± 5.67 mm Hg, and in Group L, itwas 129.30 ± 7.19 mm Hg at 0 minute, 111.77 ± 7.66 mm Hgat 2.5 minutes, and 110.27 ± 6.79 mm Hg at 5 minutes.There was no significant difference in SBP at differenttime intervals in both groups. Mean DBP at 0 minutein Group V was 88.47 ± 6.44 mm Hg, at 2.5 minutes67.63 ± 7.76 mm Hg, and at 5 minutes 68.10 ± 6.93 mm Hg,and it was 87.10 ± 7.87 mm Hg at 0 minute, 66.63 ±8.33 mm Hg at 2.5 minutes, and 66.23 ± 6.05 mm Hg at5 minutes in Group L. There was no significant differencein DBP at different time intervals in both groups. MeanHeart Rate (HR) at 0 minute in Group V was 94.23 ±6.03 bpm, at 2.5 minutes 72.93 ± 7.24 bpm, and at 5 minutes71.80 ± 11.46 bpm, and it was 91.80 ± 6.80 bpm at 0 minute,73.70 ± 8.00 bpm at 2.5 minutes, and 71.70 ± 5.83 bpm at5 minutes in Group L. There was no significant differencein HR at different time intervals in both groups.

Many studies have been done which corelate to theresult of our study. Murphy et al1 found that the KingVision Video laryngoscope was slightly faster thanMacintosh direct laryngoscope in two of four studiedairway scenarios, and had a higher success rate in thedifficult cadaver airway scenario.

Yun et al2 demonstrated that Video and opticallaryngoscopes can be used successfully by experiencedtactical paramedics in a simulated tactical setting. TheKing Vision and AirTraq resulted in improved Cormack-Lehane glottic views, but similar times to ventilation andfirst-pass success compared with direct laryngoscopy.

Akihisa et al3 showed that the King Vision Videolaryngoscope facilitated intubation by novice personnelwithout incidence of esophageal intubation.

 
We found that the first success rate for blind ILMAguidedintubation was lower that for King Vision guidedintubation. The incidence of postoperative complicationsis higher with ILMA. Being a blind technique, the chancesof failed intubation or esophageal intubation will behigher in ILMA group as shown in our study. The highincidence of esophageal intubation in our study suggeststhat early conformation of successful tracheal intubationvia ILMA is mandatory. Other complications like airwaytrauma and postoperative sore throat for ILMA groupwere higher. This may be due to high mucosal pressureexerted by cuff of ILMA. On the contrary, the videomonitor of the King Vision Video laryngoscope helps theanesthesiologist performing the tracheal intubation andthe assistant in providing the right laryngeal manipulationto improve their coordination, causing less trauma.Both the devices are useful adjuncts to intubation foruse in difficult airways, without significant differencein hemodynamic stimulation.

One advantage of the ILMA over the King Vision Videolaryngoscope is that it can provide effective ventilationbetween intubation attempts, avoiding hypoxia. Otherthan allowing ventilation in between attempts, blindintubation through the ILMA offers less advantage overKing Vision Video laryngoscope, but it is a feasible option.

Many studies have showed that the intubatinglaryngeal mask is an effective ventilation device andintubation guide with potential for use in patientswho may present difficulty in tracheal intubation.4-10Our study has a few limitations. Our study populationconsisted of only young Asian populations, who didnot have difficult airways. Our patients were healthy;hemodynamic responses may be different in patientswith cardiovascular disease.

CONCLUSION

King Vision Video laryngoscope is a more effectivetechnique in aiding endotracheal intubation in patientswith normal airways. It improved intubation times oftracheal intubation as compared with the ILMA. Blindintubation through the ILMA offers less advantageover King Vision Video laryngoscope for adult patientswith normal airways requiring intubation for electivesurgery. However, it can provide effective ventilationbetween intubation attempts and an intubation guidewith potential for use in patients who may presentdifficulty in tracheal intubation. Despite its limitations,the ILMA is a valuable adjunct to the airway management,especially in difficult airway management,when it can provide ventilation in between intubationattempts. However, the longer intubation time andgreater risk of esophageal intubation must be takeninto consideration.

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  3. Akihisa Y, Maruyama K, Koyama Y, Yamada R, Ogura A,Andoh T. Comparison of intubation performance betweenthe King Vision and Macintosh laryngoscopes in novicepersonnel: a randomized, crossover manikin study. J Anesth2014 Feb;28(1):51-57.
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  1. Bilgin H, Bozkurt M. Tracheal intubation using the ILMA,C-Trach or McCoy laryngoscope in patients with simulatedcervical spine injury. Anaesthesia 2006 Jul;61(7):685-691.
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