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      Intubation with channeled versus non-channeled video laryngoscopes in simulated difficult airway by junior doctors in an out-of-hospital setting: A crossover manikin study

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          Abstract

          Failure to secure the airway is an important cause of morbidity and mortality during resuscitations. We compared the rate of successful intubation of the King Vision aBlade channeled and non-channeled video laryngoscopes, and McGRATH MAC video laryngoscope when used by junior doctors to intubate a simulated difficult airway in an out-of-hospital setting. 105 junior doctors were recruited in a crossover study to perform tracheal intubation with the three video laryngoscopes on a simulated difficult airway using the SimMan ® 3G manikin. Primary outcome was the rate of successful intubations. Secondary outcomes were time-to-visualization, time-to-intubation and ease of use. Rates of successful intubations were higher for King Vision channeled and McGrath compared to the King Vision non-channeled (85.7% and 82.9% respectively versus 24.8%; p<0.001). Amongst the participants who had successful intubations, King Vision channeled and McGrath had shorter mean time-to-intubation compared to the King Vision non-channeled (41.3±20.3s and 38.5±18.7s respectively versus 53.8±23.8s, p<0.004;). There was no significant difference in the rate of successful intubation and mean time-to-intubation between King Vision channeled and McGrath. The King Vision channeled and McGrath video laryngoscopes demonstrated superior intubation success rates compared to King Vision non-channeled laryngoscope when used by junior doctors for intubating simulated difficult airway in an out-of-hospital setting. We postulated that the presence of a guidance channel in the King Vision channeled laryngoscope and the familiarity of the blade curvature and handling of the McGrath could have accounted for their improved intubation success rates.

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          Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation.

          Successful tracheal intubation during general anaesthesia traditionally requires a line of sight to the larynx attained by positioning the head and neck and using a laryngoscope to retract the tongue and soft tissues of the floor of the mouth. Difficulties with intubation commonly arise, and alternative laryngoscopes that use digital and/or fibreoptic technology have been designed to improve visibility when airway difficulty is predicted or encountered. Among these devices, a rigid videolaryngoscope (VLS) uses a blade to retract the soft tissues and transmits a lighted video image to a screen.
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            Early clinical experience with a new videolaryngoscope (GlideScope) in 728 patients.

            To evaluate a new videolaryngoscope and assess its ability to provide laryngeal exposure and facilitate intubation. Five centres, involving 133 operators and a total of 728 consecutive patients, participated in the evaluation of a new video-laryngoscope [GlideScope (GS)]. Many operators had limited or no previous GS experience. We collected information about patient demographics and airway characteristics, Cormack-Lehane (C/L) views and the ease of intubation using the GS. Failure was defined as abandonment of the technique. Data from six patients were incomplete and were excluded. Excellent (C/L 1) or good (C/L 2) laryngeal exposure was obtained in 92% and 7% of patients respectively. In all 133 patients in whom both GS and direct laryngoscopy (DL) were performed, GS resulted in a comparable or superior view. Among the 35 patients with C/L grade 3 or 4 views by DL, the view improved to a C/L 1 view in 24 and a C/L 2 view in three patients. Intubation with the GS was successful in 96.3% of patients. The majority of the failures occurred despite a good or excellent glottic view. GS laryngoscopy consistently yielded a comparable or superior glottic view compared with DL despite the limited or lack of prior experience with the device. Successful intubation was generally achieved even when DL was predicted to be moderately or considerably difficult. GS was abandoned in 3.7% of patients. This may reflect the lack of a formal protocol defining failure, limited prior experience or difficulty manipulating the endotracheal tube while viewing a monitor.
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              The difficult airway with recommendations for management – Part 1 – Difficult tracheal intubation encountered in an unconscious/induced patient

              Background Previously active in the mid-1990s, the Canadian Airway Focus Group (CAFG) studied the unanticipated difficult airway and made recommendations on management in a 1998 publication. The CAFG has since reconvened to examine more recent scientific literature on airway management. The Focus Group’s mandate for this article was to arrive at updated practice recommendations for management of the unconscious/induced patient in whom difficult or failed tracheal intubation is encountered. Methods Nineteen clinicians with backgrounds in anesthesia, emergency medicine, and intensive care joined this iteration of the CAFG. Each member was assigned topics and conducted reviews of Medline, EMBASE, and Cochrane databases. Results were presented and discussed during multiple teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made together with assigned levels of evidence modelled after previously published criteria. Conclusions The clinician must be aware of the potential for harm to the patient that can occur with multiple attempts at tracheal intubation. This likelihood can be minimized by moving early from an unsuccessful primary intubation technique to an alternative “Plan B” technique if oxygenation by face mask or ventilation using a supraglottic device is non-problematic. Irrespective of the technique(s) used, failure to achieve successful tracheal intubation in a maximum of three attempts defines failed tracheal intubation and signals the need to engage an exit strategy. Failure to oxygenate by face mask or supraglottic device ventilation occurring in conjunction with failed tracheal intubation defines a failed oxygenation, “cannot intubate, cannot oxygenate” situation. Cricothyrotomy must then be undertaken without delay, although if not already tried, an expedited and concurrent attempt can be made to place a supraglottic device.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: MethodologyRole: Project administrationRole: ValidationRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: MethodologyRole: Project administrationRole: Writing – review & editing
                Role: Formal analysisRole: ResourcesRole: SoftwareRole: ValidationRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: ValidationRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                22 October 2019
                2019
                : 14
                : 10
                : e0224017
                Affiliations
                [1 ] Department of Anaesthesia, National University Hospital, Singapore
                [2 ] Headquarters Army Medical Services, Singapore Armed Forces, Singapore
                [3 ] RS Anaesthesia & Intensive Care, Singapore
                Cleveland Clinic, UNITED STATES
                Author notes

                Competing Interests: The affliated commercial company ‘RS Anaesthesia & Intensive Care’ was set up by last author R. C. H. Siew RS after completion of study and played no role in the design or conduct of the study. The rest of the authors do not receive salary nor funding from R. C. H. Siew’s private anaesthesia practice. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

                Author information
                http://orcid.org/0000-0003-4336-0535
                Article
                PONE-D-19-18575
                10.1371/journal.pone.0224017
                6805049
                31639167
                38a6ccaa-0cac-46db-bfd9-bbcabc4a42fe
                © 2019 Chew et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 1 July 2019
                : 2 October 2019
                Page count
                Figures: 1, Tables: 3, Pages: 9
                Funding
                The affliated commercial company ‘RS Anaesthesia & Intensive Care’ was set up by last author R. C. H. Siew RS after completion of study and played no role in the design or conduct of the study. The rest of the authors do not receive salary nor funding from R. C. H. Siew’s private anaesthesia practice. The company did not have any role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors have declared that they did not receive any funding nor payment from any of the manufacturers of the laryngoscopes used in this study.
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