ABSTRACT
Abstract Objectives Positioning during endotracheal intubation (ETI) is critical to ensure its success. We aimed to determine if the ramping position improved laryngeal exposure and first attempt success at intubation when compared to the sniffing position. Methods PubMed, EMBASE, and Cochrane CENTRAL databases were searched systematically from inception until January 2020. Our primary outcomes included laryngeal exposure as measured by Cormack-Lehane Grade 1 or 2 (CLG 1/2), CLG 3 or 4 (CLG 3/4), and first attempt success at intubation. Secondary outcomes were intubation time, use of airway adjuncts, ancillary maneuvers, and complications during ETI. Results Seven studies met our inclusion criteria, of which 4 were RCTs and 3 were cohort studies. The meta-analysis was conducted by pooling the effect estimates for all 4 included RCTs (n = 632). There were no differences found between ramping and sniffing positions for odds of CLG 1/2, CLG 3/4, first attempt success at intubation, intubation time, use of ancillary airway maneuvers, and use of airway adjuncts, with evidence of high heterogeneity across studies. However, the ramping position in surgical patients is associated with increased likelihood of CLG 1/2 (OR = 2.05, 95% CI 1.26 to 3.32, p = 0.004) and lower likelihood of CLG 3/4 (OR = 0.49, 95% CI 0.30 to 0.79, p = 0.004), moderate quality of evidence. Conclusion Our meta-analysis demonstrated that the ramping position may benefit surgical patients undergoing ETI by improving laryngeal exposure. Large scale well designed multicentre RCTs should be carried out to further elucidate the benefits of the ramping position in the surgical and intensive care unit patients.
Resumo Objetivos A posição do paciente durante a Intubação Traqueal (IT) é fundamental para o sucesso do procedimento. Nosso objetivo foi determinar se a posição de rampa melhorou a visualização laríngea e o êxito na primeira tentativa de intubação quando comparada à posição olfativa. Métodos Os bancos de dados PubMed, EMBASE e Cochrane CENTRAL foram pesquisados de forma sistemática a partir da data em que os bancos de dados foram estabelecidos até janeiro de 2020. Nossos desfechos primários incluíram a visualização laríngea avaliada como Cormack‐Lehane Grau 1 ou 2 (CLG 1/2), Cormack‐Lehane Grau 3 ou 4 (CLG 3/4) e o êxito na primeira tentativa de intubação. Os desfechos secundários foram o tempo de intubação, uso de dispositivos adjuvantes para manuseio de vias aéreas, manobras auxiliares e complicações durante a IT. Resultados Sete estudos preencheram nossos critérios de inclusão, dos quais 4 eram Estudos Clínicos Randomizados (ECR) e 3 eram estudos de coorte. A meta‐análise foi conduzida combinando as estimativas de efeito para todos os 4 ECR incluídos (n = 632). Não foram encontradas diferenças entre as posições de rampa e olfativa para razão de chances de CLG 1/2, CLG 3/4, sucesso na primeira tentativa de intubação, tempo de intubação, uso de manobras auxiliares das vias aéreas e uso de dispositivos adjuvantes de vias aéreas, havendo evidência de alta heterogeneidade nos estudos. No entanto, a posição de rampa em pacientes cirúrgicos está associada com maior probabilidade de CLG 1/2 (OR = 2,05; 95% IC 1,26 a 3,32; p = 0,004) e menor probabilidade de CLG 3/4 (OR = 0,49; 95% IC 0,30 a 0,79; p = 0,004), com qualidade moderada de evidência. Conclusão Nossa meta‐análise demonstrou que a posição de rampa pode beneficiar pacientes cirúrgicos submetidos a IT, melhorando a visualização laríngea. ECR multicêntricos bem projetados com amostras grandes devem ser realizados para esclarecer ainda mais os benefícios da posição de rampa nos pacientes cirúrgicos e na unidade de terapia intensiva.
Subject(s)
Humans , Randomized Controlled Trials as Topic , Patient Positioning/instrumentation , Intubation, Intratracheal/methods , Posture , Time Factors , Cohort Studies , Intubation, Intratracheal/adverse effects , LarynxABSTRACT
The optimal treatments of carcinoma in situ of glottis include radiotherapy, laser surgery and vertical partial laryngectomy. Conventional surgical treatments need general anesthesia and radiotherapy has several complications. Recently, the effectiveness of 532 nm potassium titanyl phosphate (KTP) laser has been proven and widely used in vocal fold diseases even some cases of vocal fold dysplasia. A patient with difficult laryngeal exposure underwent fiberoptic laryngeal laser surgery using KTP laser under local anesthesia, showed improved voice outcome and the glottic lesion was removed successfully without local recurrence and regional metastasis 18 months after surgery.
Subject(s)
Humans , Anesthesia, General , Anesthesia, Local , Carcinoma in Situ , Glottis , Laryngectomy , Laser Therapy , Lasers, Solid-State , Neoplasm Metastasis , Potassium , Radiotherapy , Recurrence , Vocal Cords , VoiceABSTRACT
BACKGROUND AND OBJECTIVES: Laryngeal microsurgery (LMS) is a common procedure for diagnosis and treatment of various laryngeal diseases. Sometimes, laryngeal exposure is poor and LMS may be impossible. The aim of this study was to investigate factors related to difficult laryngeal exposure in LMS. SUBJECTS AND METHOD: Three hundred patients who underwent LMS were enrolled in this study. The patients were categorized into 3 subgroups (easy exposure group, moderate exposure group, and difficult exposure group) according to the glottic visualization under suspension laryngoscopy. The 14 parameters on lateral extension neck X-ray in the closed and open mouth view were analyzed to evaluate laryngeal exposure. RESULTS: The study included 168 males and 132 female patients with the mean age of 48.36+/-12.39 (10-79) years. Of 300 patients, 244 patients were classified as the easy exposure group, 41 as the moderate exposure group, and 15 as the difficult exposure group. Patients with difficult laryngeal exposure were significantly higher in males (p<0.001). Among 14 radiologic parameters, thyroid incisor angle in closed mouth view (p=0.003) and sternum-mentum distance in open mouth view (p=0.04) were significantly related with difficult laryngeal exposure on the multivariate analysis. CONCLUSION: Being a male, having a narrow thyroid incisor angle in the closed mouth view and having a short sternum-mentum distance in the open mouth view are useful patient indications that serve to predict difficult laryngeal exposure in LMS.
Subject(s)
Female , Humans , Male , Incisor , Laryngeal Diseases , Laryngoscopy , Microsurgery , Mouth , Neck , Thyroid GlandABSTRACT
BACKGROUND AND OBJECTIVES: Although difficult laryngeal exposure (DLE) is a common problem encountered during rigid laryngoscopy, no anticipatory parameters have been formally noted as its reliable predictors. The purpose of this study is to identify physical and radiologic parameters to predict DLE according to a new classification of laryngeal exposure (LE score) suggested by authors. STUDY DESIGN: Fifty-eight patients underwent larygomicrosurgery were given LE score from grade 1 to 4 according to the glottic visualization on suspension laryngoscopy using a anterior commissure laryngoscope. Several parameters to predict DLE were investigated to compare DLE cases with control. SUBJECTS AND METHOD: All patients received physical and radiological examinations that encompassed the following sixteen measurements: sex, age, modified Mallampati index (MMI), body mass index (BMI), neck circumference, anterior mandibular height (AMH), hyoid-mental distance (HMD), thyroid-mental distance (TMD), horizontal thyroid-mental distance (HTD), vertical thyroid-mental distance (VTD), sternummental distance (SMD), vertical incisor-thyroid distance (VITD), horizontal incisor-thyroid distance (HITD), thyroid incisor angle (TIA), thyroid-mandible angle (TMA) at neutral and extended positions. Modified Cormack-Lehane score (MCLS) was obtained by an anesthesiologist. Mann-Whitney U test was used to compare the control with DLE group. RESULTS: The ages of patients ranged from 23 to 80 years with a mean of 48.7 years. The LE score was highly correlated with MCLS (r=0.676, p<.001). Among physical measurements, HMD at neutral position (p=.047) and TMD (p=.016), VTD (p=.005), SMD (p=.019) and VITD (p=.040) at extended position had a statistical significance. Among radiologic measurements, HMD (p=.008) and TMD (p=.005) at neutral position, and TMD (p=.037) and VTD (p=.034) at extended position had a statistical significance. CONCLUSION: The new classification is a reliable system to evaluate the extent of laryngeal exposure during suspension laryngoscopy. The physical and radiologic measurements can be helpful to predict the difficult laryngeal exposure.