Original contribution
Indirect versus direct laryngoscopy for routine nasotracheal intubation,☆☆

https://doi.org/10.1016/j.jclinane.2010.10.003Get rights and content

Abstract

Study Objective

To compare the effectiveness of the indirect laryngoscopes, Airtraq (A) and GlideScope (G), with the Macintosh (M) laryngoscope in routine nasotracheal intubation.

Design

Randomized, single-blinded study.

Setting

University-affiliated, tertiary-care hospital.

Patients

62 adult, ASA physical status 1 and 2 patients with normal airways requiring nasotracheal intubation for dental or maxillofacial surgery.

Intervention

Patients in Groups A and G underwent nasal intubation with the Airtraq and GlideScope, respectively, while laryngoscopy in Group M was performed with the Macintosh blade.

Measurements

Performance of the intubating tools was judged by the ease [Intubation Difficulty Scale (IDS) and numeric rating scale (NRS)] and time to intubation (laryngoscopy and endotracheal tube advancement). In addition, hemodynamic parameters, severity of postoperative sore throat, and posture of the intubator were recorded.

Main Results

IDS score was significantly lower with the Airtraq and GlideScope than with the Macintosh laryngoscope (mean ± SD: A 0.1 ± 0.3, G 0.3 ± 0.6, M 0.8 ± 1.0; P = 0.013). NRS reported by the intubators showed a similar preference for indirect over direct laryngoscopy (A 0.9 ± 0.7, G 1.1 ± 0.6, M 1.9 ± 1.1; P = 0.001). Duration of laryngoscopy and endotracheal tube insertion was similar in all groups. No significant intergroup differences in hemodynamic parameters were recorded. Postoperative sore throat was significantly reduced using the GlideScope compared with the other devices (P = 0.048).

Conclusion

The Airtraq and GlideScope facilitated nasotracheal intubation more so than the Macintosh laryngoscope in adults with apparently normal airways.

Section snippets

1. Introduction

Indirect laryngoscopy may be used for nasotracheal intubation of dental and maxillofacial surgery patients. Studies involving orotracheal intubation have shown that indirect laryngoscopy consistently resulted in similar or superior laryngeal exposure compared with direct laryngoscopy [1], [2], [3], [4], [5], [6], [7], [8]. Endotracheal advancement of the nasal tube also seems to be facilitated by this approach. A recent study by Jones et al. [9] showed the superiority of the GlideScope

2. Materials and methods

This study was registered with ClinicalTrials.gov (NCT00910156). After approval by the Ethics Committee of Upper Austria and written, informed patient consent, a total of 62 patients were enrolled in this prospective, randomized study. Inclusion criteria were the need for nasotracheal intubation for elective dental or maxillofacial surgery, ASA physical status 1 or 2, and age between 18 and 80 years. Exclusion criteria were any predictors of difficult airway management (eg., history, Mallampati

3. Results

The total number of patients included in this study was 62. Two patients were withdrawn from analysis according to the exclusion criteria. One Group A patient underwent tube advancement that required more than 120 seconds, despite a CL 2 view with the Airtraq. In the other patient, who was randomized to Group M, repeated intubation attempts (> three attempts) were unsuccessful, resulting from a CL 4 grade laryngoscopic view.

All 60 patients who remained in the study underwent successful

4. Discussion

In this study, IDS and NRS were chosen as endpoints to compare ease of routine nasotracheal intubation using indirect laryngoscopes versus the traditional Macintosh laryngoscope. In our opinion, IDS and NRS appear to be the best indicators of intubation difficulties available thus far. While NRS is a very subjective assessment, IDS was applied to more objectively compare intubating conditions [7], [12]. With the highest score of 3, IDS values of all included 60 intubations were consistently low

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  • Videolaryngoscopy versus direct laryngoscopy for nasotracheal intubation: A systematic review and meta-analysis of randomised controlled trials

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    Two studies [37,38] used a 0–100 mm visual analogue scale (0 being ‘worst’ and 100 ‘best’), and results were not pooled due to significant heterogeneity; 3 [6,38,42] used the Intubation Difficulty Scale (IDS) score, and one [20] used a modified naso-intubation difficulty scale (MNIDS). Punchner et al. [6] also used a numeric rating scale (NRS, 0 being ‘easiest’ and 10 “the most difficult’) to rate difficulties in managing the airway; the ease of intubation was classified as easy or difficult in one study [34]. The above all studies showed a significant difference in the ease of intubation between groups, with VL being superior to DL (p < 0.05).

  • McGrath Video Laryngoscopy Facilitates Routine Nasotracheal Intubation in Patients Undergoing Oral and Maxillofacial Surgery: A Comparison with Macintosh Laryngoscopy

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    Other indirect laryngoscopes (GlideScope and Airtraq [Prodol Meditec SA, Vizcaya, Spain]) improve the Cormack and Lehane glottic grade and require less OELM for routine nasotracheal intubation than the Macintosh laryngoscope.9 The same study reported a considerably lower intubation difficulty scale (IDS) score during routine nasotracheal intubation compared with direct laryngoscopy.9 Despite the lack of IDS scoring, IDS values might have been lower in the McGrath group than in the Macintosh group owing to better glottic views before OELM and less need for OELM and Magill forceps.

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    In contrast to the indirect laryngoscope, direct laryngoscopes require a greater lifting force, increased laryngeal pressure, and other manipulations for glottic visualization.5 The results are in accordance with previous trials that have documented statistical decreases in the IDS score with indirect versus direct laryngoscopes.11–13 In the present study, the rate of successful intubation using the Macintosh laryngoscope or Truview laryngoscope was similar (100% in 2 attempts), with none of the patients requiring a third attempt for intubation.

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The authors have no conflicts of interest to report.

☆☆

Support: departmental funding only.

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