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      TotalTrack video intubating laryngeal mask in super-obese patients – series of cases

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          Abstract

          Background

          Super-obese patients are at increased risk of difficult mask ventilation and difficult intubation. Therefore, devices that allow for simultaneous ventilation/oxygenation during attempts to visualize the entrance to the larynx, increase patient safety. TotalTrack video intubating laryngeal mask is a new device that allows for ventilation during intubation efforts.

          Patients and methods

          Twenty-four super-obese patients (body mass index >50 kg/m 2) were divided into two subgroups: intubation efforts using 1) TotalTrack and 2) Macintosh blade standard laryngoscope in induction of general anesthesia. Visualization and successful intubation was evaluated for both groups with ventilation and post-mask complications additionally evaluated for TotalTrack.

          Results

          In all cases in the TotalTrack group, the Cormack-Lehane score was 1, ventilation and intubation was successful in 11/12 patients. No hypoxia during intubation efforts was recorded. No serious complications of use of TotalTrack were observed. In the Macintosh blade laryngoscope group, all patients were intubated, but the Cormack-Lehane score was 2 in four cases, and 3 in three cases.

          Conclusion

          TotalTrack video intubating laryngeal mask is a device that allows for better visualization of the larynx compared to the standard Macintosh blade laryngoscope, it provides effective ventilation/oxygenation and intubation in super-obese patients.

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          Most cited references 13

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          High body mass index is a weak predictor for difficult and failed tracheal intubation: a cohort study of 91,332 consecutive patients scheduled for direct laryngoscopy registered in the Danish Anesthesia Database.

          Previous studies have failed to detect high body mass index (BMI) as a risk factor for difficult tracheal intubation (DTI). BMI was investigated as a risk factor for DTI in patients planned for direct laryngoscopy. A cohort of 91,332 consecutive patients planned for intubation by direct laryngoscopy was retrieved from the Danish Anesthesia Database. A four-point scale to grade the tracheal intubation was used. Age, sex, American Society of Anesthesiologists physical status classification, priority of surgery, history of previous DTI, modified Mallampati-score, use of neuromuscular blocker, and BMI were retrieved. Logistic regression to assess whether BMI was associated with DTI was performed. The frequency of DTI was 5.2% (95% confidence interval [CI] 5.0-5.3). In multivariate analyses adjusted for other significant covariates, BMI of 35 or more was a risk for DTI with an odds ratio of 1.34 (95% CI 1.19-1.51, P < 0.0001). As a stand alone test, BMI of 35 or more predicted DTI with a sensitivity of 7.5% (95% CI 7.3-7.7%) and with a predictive value of a positive test of 6.4% (95% CI 6.3-6.6%). BMI as a continuous covariate was a risk for failed intubation with an odds ratio of 1.031 (95% CI 1.002-1.061, P < 0.04). High BMI is a weak but statistically significant predictor of difficult and failed intubation and may be more appropriate than weight in multivariate models of prediction of DTI.
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            Tracheal intubation of morbidly obese patients: a randomized trial comparing performance of Macintosh and Airtraq laryngoscopes.

            The Airtraq laryngoscope is designed to allow visualization of the glottis without alignment of the oral, pharyngeal, and laryngeal axes. We hypothesized that this new airway device would facilitate tracheal intubation of morbidly obese patients. We compared tracheal intubation performance of standard Macintosh laryngoscope with the Airtraq laryngoscope in morbidly obese patients. One hundred and six consecutive ASA I-III morbidly obese patients undergoing surgery were randomized to intubation with the Macintosh laryngoscope or the Airtraq laryngoscope. Induction of anaesthesia was standardized. If tracheal intubation failed within 120 s with the Macintosh or Airtraq , laryngoscopes were switched. Success rate, SpO2, duration of tracheal intubation, and quality of airway management were evaluated and compared between the groups. Preoperative characteristics of the patients were similar in both groups. In the Airtraq group, tracheal intubation was successfully carried out in all patients within 120 s. In the Macintosh laryngoscope group, six patients required intubation with the Airtraq laryngoscope. The mean (SD) time taken for tracheal intubation was 24 (16) and 56 (23) s, respectively, with the Airtraq and Macintosh laryngoscopes, (P<0.001). SpO2 was better maintained in the Airtraq group than in the Macintosh laryngoscope group with one and nine patients, respectively, demonstrating drops of SpO2 to 92% or less (P<0.05). In this study, the Airtraq laryngoscope shortened the duration of tracheal intubation and prevented reductions in arterial oxygen saturation in morbidly obese patients.
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              Perioperative management of obese patients.

              Obesity is a metabolic disease that is on the increase all over the world. Up to 35% of the population in North America and 15-20% in Europe can be considered obese. Since these patients are characterised by several systemic physiopathological alterations, the perioperative management may present some problems, mainly related to their respiratory system. Body mass is an important determinant of respiratory function before and during anaesthesia not only in morbidly but also in moderately obese patients. These can manifest as (a) reduced lung volume with increased atelectasis; (b)derangements in respiratory system, lung and chest wall compliance and increased resistance; and (c) moderate to severe hypoxaemia. These physiological alterations are more marked in obese patients with hypercapnic syndrome or obstructive sleep apnoea syndrome. The suggested perioperative ventilation management includes (a) awake and/or facilitated endotracheal intubation by using a video-laryngoscope; (b) tidal volume of 6-10 ml kg(-1) ideal body weight, increasing respiratory rate to maintain physiological PaCO2, while avoiding intrinsic positive end-expiratory pressure (PEEPi); and (c) a recruitment manoeuvre (35-55 cmH2O for 6 s) followed by the application of an end-expiratory pressure (PEEP) of 10 cmH2O. The recruitment manoeuvre should always be performed only when a volemic and haemodynamic stabilisation is reached after induction of anaesthesia. In the postoperative period, beach chair position, aggressive physiotherapy, noninvasive respiratory support and short-term recovery in intermediate critical care units with care of fluid management and pain may be useful to reduce pulmonary complications.
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                Author and article information

                Journal
                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                1176-6336
                1178-203X
                2016
                02 March 2016
                : 12
                : 335-338
                Affiliations
                Department of Emergency and Disaster Medicine, Medical University of Lodz, Lodz, Poland
                Author notes
                Correspondence: Tomasz Gaszynski, Department of Emergency and Disaster Medicine, Medical University of Lodz, ul. Kopcinskiego 22, 90-153 Lodz, Poland, Tel +48 42 678 37 48, Email tomasz.gaszynski@ 123456umed.lodz.pl
                Article
                tcrm-12-335
                10.2147/TCRM.S95695
                4780402
                27042078
                © 2016 Gaszynski. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Categories
                Original Research

                Medicine

                video laryngoscope, standard laryngoscope, laryngeal mask, ventilation, intubation, super-obese

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