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In most of these studies, success was defined not only by accurate anatomic placement of the endotracheal tube (ETT), but also by absence of significant complications [3-7]. Moreover, prehospital ETI was soon correlated with positive outcomes particularly in the most dire of circumstances [7,8,15].

Endo Tracheal Intubation Pdf Download


Endotracheal intubation in the out-of-hospital setting. In the early years of out-of-hospital emergency medical services (EMS) systems, advanced life support personnel were not only trained in the nuances of how to avoid overzealous ventilation and properly place an endotracheal tube in very challenging circumstances, but they were also well-supervised on-scene by expert physicians who themselves were highly-experienced and exceptionally familiar with those challenges as well as methods to overcome them (photo by Dr. Paul Pepe).

Endotracheal intubation in the ICU is a challenging procedure and is frequently associated with life-threatening complications. The aim of this study was to investigate the effect of the C-MAC video laryngoscope on laryngeal view and intubation success compared with direct laryngoscopy.

In a single-center, prospective, comparative before-after study in an anesthetist-lead surgical ICU of a tertiary university hospital, predictors of potentially difficult tracheal intubation, number of intubation attempts, success rate and glottic view were evaluated during a 2-year study period (first year, Macintosh laryngoscopy (ML); second year, C-MAC).

A total of 274 critically ill patients requiring endotracheal intubation were included; 113 intubations using ML and 117 intubations using the C-MAC were assessed. In patients with at least one predictor for difficult intubation, the C-MAC resulted in more successful intubations on first attempt compared with ML (34/43, 79% vs. 21/38, 55%; P = 0.03). The visualization of the glottis with ML using Cormack and Lehane (C&L) grading was more frequently rated as difficult (20%, C&L grade 3 and 4) compared with the C-MAC (7%, C&L grade 3 and 4) (P

Use of the C-MAC video laryngoscope improved laryngeal imaging and improved the intubating success rate on the first attempt in patients with predictors for difficult intubation in the ICU setting. Video laryngoscopy seems to be a useful tool in the ICU where potentially difficult endotracheal intubations regularly occur.

Video laryngoscopes seem promising for airway management [7]. Video laryngoscopes contain a small camera and a light source at the distal third of the blade. The video picture is transferred to a monitor. The C-MAC video laryngoscope (Karl Storz GmbH & Co. KG, Tuttlingen Germany) evaluated in this study uses Macintosh-shaped blades. Two approaches to visualize the glottis with the use of a Macintosh video laryngoscope blade are available: first, the direct view of the glottis; and second, an indirect view by means of a miniature camera on the screen of the monitoring unit. Several studies have shown the successful use of the C-MAC in the operating room and in prehospital emergency medicine [8, 9]. The use of Macintosh blades with the C-MAC improved the glottic view in patients who were difficult to intubate using direct laryngoscopy in the operating room [10]. These data cannot be directly translated to the situation on the ICU, because performing endotracheal intubation is more challenging in this environment.

The aim of this study was to evaluate the glottic view, number of intubation attempts and success rate of endotracheal intubation in an anesthetist-lead surgical ICU using Macintosh laryngoscopy (ML) or the C-MAC video laryngoscope. Additionally, we evaluated whether the level of physician experience might influence visualization of the glottis or intubation success. We hypothesized that the use of a video laryngoscope would improve the glottic view and reduce the number of intubation attempts.

This prospective, comparative, before-after study evaluated the endotracheal intubations of critically ill patients over a 2-year period in the ICU. Participating physicians completed a standardized evaluation form immediately after performing an endotracheal intubation.

Predictors of potentially difficult tracheal intubation were recorded for each patient on the standardized evaluation form: short neck with large circumference, obesity, limited mouth opening (

Over a 12-month evaluation period (January 2009 to January 2010), the standard procedures for tracheal intubation remained unchanged. Restrictions concerning the selection of airway management tools for endotracheal intubation did not exist (baseline). Direct laryngoscopy (ML) was performed using a size 3 or size 4 regular Macintosh blade. Alternative airway devices (for example, intubation endoscope, laryngeal mask airway, and cricothyrotomy set) were always available in an airway cart at the bedside. After three failed attempts at endotracheal intubation, alternative devices (for example, endoscopic intubation) were used according to the in-house difficult airway algorithm.

The presence of at least two healthcare professionals, with at least one senior physician, was standard for all intubations. If possible, pre-oxygenation for 3 minutes at a high constant flow or non-invasive positive-pressure ventilation was administered to the patients. The medication for the induction of anesthesia was sufentanil (0.3 to 1.0 μg/kg) in every patient, with either propofol (1.5 to 2.0 mg/kg), ketamine (1.5 to 3 mg/kg) or etomidate (0.2 to 0.3 mg/kg). Rocuronium (0.4 to 0.9 mg/kg) was always used for neuromuscular blockade. In cardiac arrest patients, intubations were performed without medication. A malleable stylet in a hockey-stick shape was always used for tube placement. If visualization of the glottis or the placement of the endotracheal tube was difficult, the manipulation of the larynx was performed according to the instructions of the laryngoscopist. The successful placement of the endotracheal tube was confirmed using capnography.

We then evaluated endotracheal intubations over a second 12-month period (February 2010 to February 2011) after implementing two C-MAC video laryngoscopes (Karl Storz GmbH & Co. KG) in the ICU (intervention phase). Video laryngoscopy was performed using the Karl Storz Macintosh shaped blades for C-MAC size 3 or size 4 (Figure 1). ICU physicians were given didactic instruction on the proper use of the C-MAC along with training on manikins. The ICU staff were advised to perform endotracheal intubations using the C-MAC instead of ML when appropriate. The procedures for intubation, the medication for anesthesia and the in-house difficult airway algorithm were identical to the first evaluation period. Documentation was identical to the previous study period of 2009 to 2010.

With the availability of the video laryngoscope, more physicians-in-training performed endotracheal intubations. In contrast, mainly specialists performed endotracheal intubations during the baseline phase (P

During the baseline phase of the study, a total of 113 intubations were performed using ML. A total of 117 intubations were performed using the C-MAC during the intervention phase of the study. After the introduction of a video laryngoscope, the use of intubating endoscopy was used less frequently used for intubation compared with the baseline phase (5/134, 4% vs. 18/140, 13%; P

Complications during endotracheal intubations occurred in 17 (12%) cases in the baseline phase of the study and in 14 (10%) patients after the C-MAC was introduced in the intervention phase of the study (P = 0.7; Table 3). The types of complications did not differ between the groups. The oxygenation saturation as measured by pulse oximetry did not differ between groups (Table 3).

The number of attempts needed for securing the airway of patients was not different between the ML and the C-MAC groups (P = 0.21; Figure 2). The rate for difficult intubation (using the definition of at least two failed intubation attempts) was 7% and 3% in the ML and C-MAC groups, respectively (Figure 2). The rate of success for the first intubation attempt did not differ when the C-MAC was used compared with ML (103/117, 88% vs. 89/113, 79%; P = 0.08). If at least one predictor for potential difficult intubation was present, the success rate for endotracheal intubation at the first attempt was higher (34, 79%) in the C-MAC group compared with the ML group (22, 56%; P = 0.03) (Table 4).

In this prospective study of 247 consecutive patients over a 2-year period, endotracheal intubation was associated with a high rate of difficult laryngeal visualization and a high number of repeated intubation attempts. The use of the C-MAC video laryngoscope improved visualization of the glottis during airway management in the ICU. Patients with a potential difficult airway had a higher success rate for intubation at the first attempt when the video laryngoscope was used.

The major advantage of video laryngoscopes is that the glottis can be visualized indirectly via a screen without a direct line of view (look around the corner). One potential problem is that the tip of the endotracheal tube has to pass a sharp angle to enter the larynx, which increases the risk of contact with the anterior tracheal wall. As a result, the tube cannot be easily advanced into the trachea. This phenomenon has been described with the use of several video laryngoscopes, such as the McGrath Series 5 (Aircraft Medical Ltd, Edinburgh, UK) and the GlideScope (Verathon Inc., Bothell, WA, USA). The use of a video laryngoscope with a Macintosh shaped video blade reduced the problem of tube advancement despite a good glottic view compared with the video laryngoscopes that use a more curved blade. In a comparison of the use of ML versus the use of the C-MAC in groups of patients who had a difficult laryngoscopy during a scheduled surgical procedure, the use of the C-MAC improved the glottic view in 94% (49/52) of patients [10]. In the operating room, use of the C-MAC in patients with a predicted difficult airway improved optical access to the glottis compared with direct laryngoscopy using a Macintosh laryngoscope and resulted in more successful intubations at the first attempt [13]. 350c69d7ab


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