Intubation of Critically Ill COVID-19 Patients Using Conventional Laryngoscope in the ICU

Background: Video laryngoscopy is recommended for critically ill COVID-19 patients due to safety concerns and avoid complications. It is not available in some places and thereby forcing the operator to rely on conventional laryngoscope. Intubations in critically ill COVID-19 patients are challenging and may lead to adverse complications which may be affected by the laryngoscope used. The aim of the study was to analyse predictors of difficult intubation, complexity of intubation and complications of using conventional laryngoscopy in intubations of COVID-19 patients in ICU. Method(s): A prospective observational study was done in COVID Intensive Care Unit of the Base Hospital-Teldeniya, Sri Lanka from 1st of January 2021 to August 2021. The data was collected using a Performa filled by operator at the end of the intubation. Apart from demographic data and clinical parameters, data related to intubation including MACOCHA score which is a validated score predicting difficult intubation in ICU(3) and Intubation difficulty scale (IDS) which measures the actual complexity of intubation(4) were collected. The complications related to intubation were also analysed. Result(s): Approximately 84 out of 91 emergency intubations were done using conventional laryngoscope. Out of them 50.72 % were male and 49.27% Were female. Mean age was 50.75 years. First pass success rate was 83.3%. 25% had MACOCHA score more than 3. Most patients scored on the desaturation component of the score. Despite this only 50% of the predicted difficult intubations actually had major difficulty in intubation. The commonest complication was hypotension. 12 had suffered cardiac arrest, and 4 of them were fatal. Conclusion(s): Intubation of Critically ill COVID-19 patients are challenging but can be done successfully with conventional laryngoscope. However, one must prepare for complications including cardiac arrest.Copyright © 2023, College of Anaesthesiologists of Sri Lanka. All rights reserved.

A case report on anesthetic challenges in the post-Covid complication of active mucormycosis: Patient preparedness for family physicians.

Mucormycosis is a well-known yet complicated illness that seems benign but behaves malignantly. This article discusses the anesthesia challenges in providing care for a 49-year-old male who presented with post-Covid pneumonia and uncontrolled diabetes along with active mucormycosis and scheduled for functional endoscope sinus surgery (FESS) and debridement of necrotic tissue. We want to illustrate the importance of anticipated difficult airway, while highlighting the toxicity of intravenous amphotericin-B and its combination against anesthesia drugs.

The relationship between years of anesthesia experience and first-time intubation success rate with direct laryngoscope and video laryngoscope in infants: a retrospective observational study.

PURPOSE: Studies in adults have reported that video laryngoscope is more useful than direct laryngoscope when training less experienced anesthesiologists. However, whether this is true for infants remains unclear. Therefore, this study aimed to evaluate whether the use of video laryngoscope would result in smaller differences in success rate according to anesthesiologists' expertise than those in direct laryngoscope. METHODS: Medical records and video recordings from the operating room of patients aged < 1 year who underwent non-cardiac surgery between March 2019 and September 2021 were reviewed. Tracheal intubations between April 8, 2020, and June 20, 2021, were excluded due to the shortage of video laryngoscope blades during the COVID-19 pandemic. Rates of first-time tracheal intubation success were compared by years of anesthesia experience and initial intubation device. RESULTS: In total, 125 of 175 tracheal intubations were analyzed (direct laryngoscope group, n = 72; video laryngoscope group, n = 53). The first-time tracheal intubation success rate increased with years of experience as an anesthesiologist in the direct laryngoscope group (odds ratio OR 1.70, 95% confidence interval CI 1.15, 2.49; P = 0.0070), but not the video laryngoscope group (OR 0.99, 95% CI 0.74, 1.35; P = 0.99). CONCLUSION: The differences in success rate according to the anesthesiologists' years of experience were non-significant when using video laryngoscope in infants, compared to those in direct laryngoscope.

Cuff inflation technique is better than Magill forceps technique to facilitate nasotracheal intubation guiding by GlideScope® video laryngoscope.

Video laryngoscopy is often selected to assist nasotracheal intubation in allowing better laryngeal visualization, although there is no comparative study evaluating the effectiveness between auxiliary techniques by using Magill forceps and inflated cuff in GlideScope video laryngoscopy for nasotracheal intubation. Fifty-one of 100 patients in a Magill forceps group and 47 of 100 patients in a cuff inflation group were included in the final analysis in this randomized, single-blind, parallel, clinical trial study. Induction agents were routinely administered according to body weight, while intubation time spent, attempts, and related side effects were recorded. Compared to the Magill forceps group, the cuff inflation technique shortened the total intubation time (70.0 ± 24.5 s vs. 87.0 ± 25.0 s, p = 0.001) and the time of advancing the nasotracheal tube from oropharyngeal space into the trachea (25.9 ± 16.4 s vs. 42.3 ± 21.2 s, p < 0.001). However, the number of intubation attempts was not significantly different between groups. During tube advancement, the tube was rotated to accommodate the glottis and trachea more frequently in the cuff inflation group (p = 0.009), but the blade of the laryngoscope shifted and was adjusted to the proper position more frequently in the Magill forceps group (p < 0.001). In the Magill forceps group, the tube cuff might be clipped incidentally and the intubator might shift their gaze away from the screen during intubation, although there was no significant difference in intubation-related side effects between groups. Unlike the conventional approach, nasotracheal intubation with the GlideScope® video laryngoscope using the auxiliary technique of cuff inflation could be more suited than using Magill forceps.

Airway Management of Patients with Suspected or Confirmed COVID-19: Survey Results from Physicians from 19 Countries in Latin America.

Airway management during the COVID-19 pandemic has been one of the most challenging aspects of care that anesthesiologists and intensivists face. This study was conducted to evaluate the management of tracheal intubation in patients with suspected or confirmed COVID-19 infection. This is a cross-sectional and international multicenter study based on a 37-item questionnaire. The survey was available to physicians who had performed intubations and tracheostomies in patients with suspected or confirmed COVID-19 and had provided informed consent to participate. The primary outcome is the preference to use a specific device for tracheal intubation. Secondary outcomes are clinical practice variables, use of video laryngoscopes, difficult airway management, and safety features to prevent cross-infection. This study included 2411 physicians who performed an average of 11.90 and 20.67 tracheal intubations in patients diagnosed or suspected of having COVID-19 disease, respectively. Physicians were mainly from the specialties of Anesthesiology (61.2%) and Intensive Care (7.4%). COVID-19 infection diagnosed by positive PCR or serology in physicians participating in intubation in this study was 15.1%. Respondents considered preoxygenation for more than three minutes very useful (75.7%). The preferred device for tracheal intubation was the video laryngoscope (64.8%). However, the direct laryngoscope (57.9%) was the most commonly used, followed by the video laryngoscope (37.5%). The preferred device to facilitate intubation was the Eschmann guide (34.2%). Percutaneous tracheostomy was the preferred technique (39.5%) over the open tracheostomy (22%). The predicted or unpredicted difficult airway management in these patients was preferably performed with a video laryngoscope (61.7% or 63.7, respectively). Intubation was mostly performed by two or more expert airway physicians (61.6%). The use of personal protective equipment increased the practitioners' discomfort during intubation maneuvers. The video laryngoscope is the preferred device for intubating patients with COVID-19, combined with the Eschmann guide, flexible stylet within the endotracheal tube, or Frova guide to facilitate intubation. The sub-analysis of the two groups of physicians by the level of intubation experience showed a higher use of the video laryngoscope (63.4%) in the experts group and no significant differences between the two groups in terms of cross-infection rates in physicians, in their preference for the use of the video laryngoscope or in the number of intubations performed in confirmed or suspected COVID-19 patients.

Comparison of endotracheal intubation with Macintosh versus King Vision video laryngoscope using coronavirus disease 2019 barrier box on manikins: A randomized crossover study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) virus usually spreads through aerosol and close contact. Frontline health-care workers handle aerosol-generating procedures like endotracheal intubation. To reduce this risk, COVID-19 barrier box came into the picture. However, the COVID-19 barrier box may compromise easy and successful intubation, and their limitation must be studied. OBJECTIVES: The objective of this study was to assess the time to successful intubation with or without the COVID-19 barrier box using the Macintosh laryngoscope and King Vision video laryngoscope (KVVL). We also assessed the first-pass success rate, ease of intubation, Cormack-Lehane (CL) grade, and requirement of external laryngeal manipulation. METHODS: We conducted this manikin-based randomized crossover study to assess the time to successful intubation by anesthesiologists (22) and emergency physicians (11) having 1 year or more experience with or without COVID-19 barrier box by using the Macintosh laryngoscope and KVVL. Our study randomized the sequence of the four different intubation scenarios. RESULTS: The comparison of mean duration of intubation between KVVL (13.21 ± 4.05 s) and Macintosh laryngoscope (12.89 ± 4.28 s) with COVID-19 barrier box was not statistically significant (95% confidence interval: 1.21-0.97). The ease of intubation, number of attempts, and requirement of external laryngeal manipulation were not statistically significant. Intubations were statistically significant more difficult with barrier box in view of higher CL grade. CONCLUSION: Time to intubation was longer with COVID-19 barrier box using KVVL as compared to Macintosh laryngoscope which was statistically not significant.

Airway management of COVID-19 patients: A survey on the experience of 1125 physicians in Spain.

BACKGROUND: We explored the experience of clinicians from the Spanish Society of Anesthesiology (SEDAR) in airway management of COVID-19 patients. METHODS: An software-based survey including a 32-item questionnaire was conducted from April 18 to May 17, 2020. Participants who have been involved in tracheal intubations in patients with suspected or confirmed COVID-19 infection were included anonymously after obtaining their informed consent. The primary outcome was the preferred airway device for tracheal intubation. Secondary outcomes included the variations in clinical practice including the preferred video laryngoscope, plans for difficult airway management, and personal protective equipment. RESULTS: 1125 physicians completed the questionnaire with a response rate of 40,9%. Most participants worked in public hospitals and were anesthesiologists. The preferred device for intubation was the video laryngoscope (5.1/6), with the type of device in decreasing order as follows: Glidescope, C-MAC, Airtraq, McGrath and King Vision. The most frequently used device for intubation was the video laryngoscope (70,5%), using them in descending order as follow: the Airtraq, C-MAC, Glidescope, McGrath and King Vision. Discomfort of intubating wearing personal protective equipment and the frequency of breaching a security step was statistically significant, increasing the risk of cross infection between patients and healthcare workers. The opinion of senior doctors differed from younger physicians in the type of video-laryngoscope used, the number of experts involved in tracheal intubation and the reason that caused more stress during the airway management. CONCLUSIONS: Most physicians preferred using a video-laryngoscope with remote monitor and disposable Macintosh blade, using the Frova guide.

Anticipated Difficult Airway Management with Ambuscope in a Patient with Rhino-Orbito-Cerebral Mucormycosis

Management of a difficult airway can be a nightmare for even an experienced anaesthesiologist. Video laryngoscopes have been mentioned in the difficult airway cart as a requisite equipment according to 2016 All India difficult airway guidelines. Ambuscope is a recently introduced flexible videoscope which is portable, light weight and single use device. This was a case of 25-year-old male who presented with loss of vision in both eyes and diffuse swelling of the face in the Ophthalmology Department. A diagnosis of post Coronavirus Disease-19 (COVID-19), Rhino-orbito-cerebral mucormycosis was made. Further patient was scheduled for emergency surgical debridement and bilateral orbital exentration under general anaesthesia. Airway assessment revealed mouth opening of one finger, Mallampati (MPG) score of 4, thyromental distance of 4.5 cm and a receding mandible with normal neck flexion and extension. Ambuscope (TM) 3 was employed for facilitating endotracheal intubation after anaesthesia induction. Ambuscope is a useful aid in confirming the position of endotracheal tubes and tracheostomy tubes in the operating room and intensive care unit. They are a disposable, convenient and practical alternative to fibreoptic bronchoscopes in patients of difficult airway. Ambuscope (TM) 3 has tip movements with 150 degrees up and 130 degrees down. These unique features make this equipment user-friendly in anticipated and unanticipated difficult airway scenarios. Flexible endoscopes have carved a niche for themselves in the armamentarium of the anaesthesiologist airway cart to be equipped for any challenge.

[Airway management of COVID-19 patients: a survey on the experience of 1125 physicians in Spain]. / Manejo de vía aérea en pacientes COVID-19: una encuesta sobre la experiencia de 1125 médicos en España.

BACKGROUND: We explored the experience of clinicians from the Spanish Society of Anesthesiology in airway management of COVID-19 patients. METHODS: An software-based survey including a 32-item questionnaire was conducted from April 18 to May 17, 2020. Participants who have been involved in tracheal intubations in patients with suspected or confirmed COVID-19 infection were included anonymously after obtaining their informed consent. The primary outcome was the preferred airway device for tracheal intubation. Secondary outcomes included the variations in clinical practice including the preferred video laryngoscope, plans for difficult airway management, and personal protective equipment. RESULTS: 1125 physicians completed the questionnaire with a response rate of 40,9%. Most participants worked in public hospitals and were anesthesiologists.The preferred device for intubation was the video laryngoscope (5.1/6), with the type of device in decreasing order as follows: Glidescope, C-MAC, Airtraq, McGrath and King Vision. The most frequently used device for intubation was the video laryngoscope (70,5%), using them in descending order as follow: the Airtraq, C-MAC, Glidescope, McGrath and King Vision.Discomfort of intubating wearing personal protective equipment and the frequency of breaching a security step was statistically significant, increasing the risk of cross infection between patients and physicians. The opinion of senior doctors differed from younger physicians in the type of video-laryngoscope used, the number of experts involved in tracheal intubation and the reason that caused more stress during the airway management. CONCLUSIONS: Most physicians preferred using a video-laryngoscope with remote monitor and disposable Macintosh blade, using the Frova guide.

Comparative performance of two protective barriers during tracheal intubation of COVID-19 patients: A simulation cross-over study.

COVID-19 was declared a pandemic by the WHO in 2020. In light of the global shortage of PPE and concerns regarding the safety of healthcare providers, clinicians have resorted to the use of novel protective barriers, such as aerosol boxes and plastic sheets, during aerosol generating procedures, especially tracheal intubation. We compared the effect of these barriers on the tracheal intubation of simulated patients with severe COVID-19 in a crossover study. The study was approved by the Ethics Committee of King Faisal Specialist Hospital, and the procedures were compliant with the COVID-19 airway management guidelines of the Saudi Anesthesia Society. The time to intubation was our primary outcome. Secondary outcomes included number of optimization maneuvers, number of intubation attempts, time to glottic view and ventilation of the lungs, and damage to PPE. Thirteen consultant anesthetists performed 39 tracheal intubations on a manikin using each of three approaches (aerosol box, plastic sheet, and no-barrier). Data were collected via direct and video observation. The plastic sheet approach demonstrated the highest time to intubation (mean ± StE [95% CI]: 33.3s ± 3.5 [25.8- 40.9]) compared to the aerosol box (22.0s ± 2.5 [16.5 - 27.5], P < 0.01) and no-barrier approaches (16.1s ± 1.1 [13.7 - 18.4], P < 0.0001). Similarly, the plastic sheet approach had the highest time to glottic view, and ventilation intervals compared to the other two approaches, while the no-barrier approach had the shortest time intervals. There were no failed intubations or damage to the PPE sustained during the use of any of the three approaches. The aerosol box does not impose a significant delay in tracheal intubation using video laryngoscopy, unlike the plastic sheet barrier. Further research on the aerosolization risk is warranted before these protective barriers can be considered as mainstay approaches during aerosol generating procedures.

Macintosh laryngoscope and i-view™ and C-MAC® video laryngoscopes for tracheal intubation with an aerosol box: a randomized crossover manikin study.

BACKGROUND: We tested the hypothesis that the C-MAC® video laryngoscope (C-MAC) with an external display is more useful than the disposable i-view™ video laryngoscope (i-view) with an integrated display or a Macintosh direct laryngoscope (Macintosh) for tracheal intubation with an aerosol box. METHODS: In this randomized, crossover manikin study, we recruited 37 medical personnel with > 2 years of dedicated anesthesia experience from five hospitals. After the three successful intubations within 60 s using each laryngoscope without a box, the participants performed tracheal intubation thrice with each laryngoscope with at least 2-h intervals in a determined order. The primary outcome was the intubation time. The secondary outcomes were success rate, Cormack-Lehane grade, and subjective difficulty scale score. RESULTS: Thirty-seven personnel (11 women and 26 men) with 12 [5-19] (median [interquartile range]) years of anesthesia and intensive care experience were enrolled. There was no significant difference in the intubation time: 30 [26-32] s for Macintosh, 29 [26-32] s for i-view, and 29 [25-31] s for C-MAC (P = 0.247). The success rate was 95-100%, without a significant difference (P = 0.135). The i-view and C-MAC exhibited superior Cormack-Lehane grades and lower subjective difficulty scale scores than the Macintosh; however, there were no differences between the i-view and C-MAC. CONCLUSIONS: Rapid and highly successful tracheal intubation was possible with both Macintosh, i-view, and C-MAC on a normal airway manikin in an aerosol box. Improved Cormack-Lehane grade and the ease of performing the procedure may support the use of video laryngoscopes. TRIAL REGISTRATION: UMIN Clinical Trials Registry, UMIN000040269 . Registered 30 April 2020.

Comparison of Mc Grath-MAC and C-MAC video laryngoscopes for intubation in a COVID simulated mannequin by novice users wearing face protective gear: A randomized crossover trial.

INTRODUCTION: Intubation in COVID patients is challenging. Various guidelines suggest the use of video-laryngoscope (VL) as the first device to aid intubation in a COVID patient. The best VL to facilitate intubation in such a setting especially by novices is not ascertained. We compared intubation characteristics by two VL's (McGrath-MAC and C-MAC) for intubation in a COVID simulated mannequin by novices. METHODOLOGY: This prospective randomized manikin-based crossover study was done in thirty medical professionals with no previous experience of intubation with VL. All participants were trained on Laerdel airway management trainer and were allowed 5 practice sessions with each scope with an intubation box while wearing face protective personal protective equipment (PPE). Participants were randomized into two groups of 15 each, one group performed the intubation first with McGrath and the other with C-MAC before crossing over. RESULTS: The mean (S. D.) time to intubation was similar with both McGrath-VL and CMAC VL [31.33 (14.72) s vs 26.47 (8.5) s, P = (p-0.063)]. POGO score [mean (S. D.)] was better with CMAC [81.33 (16.24) vs 60.33 (14.73), p-0.00. The majority of the users preferred C-MAC VL for intubation (93.33%). The incidence of failed intubation and multiple attempts at intubating were similar with the two scopes. CONCLUSION: The time to intubation was similar with both VL's but the majority of novices preferred CMAC probably due to a bigger screen that helped them to have a better view of glottis in the COVID simulated mannequin.

Video Laryngoscopy Improves Intubation Times With Level C Personal Protective Equipment in Novice Physicians: A Randomized Cross-Over Manikin Study.

BACKGROUND: The use of video laryngoscopes by novice physicians may improve first-pass success rates compared with direct laryngoscopy. OBJECTIVE: The aim of the present study was to assess whether time to intubation, number of laryngoscopy attempts, and first-pass success rate during laryngoscopy with the video laryngoscope or conventional Macintosh laryngoscope are affected by personal protective equipment (PPE) donning. METHODS: Seventy inexperienced physicians were randomly assigned to video laryngoscope or Macintosh groups and were instructed to perform intubation with both devices on a manikin, using PPE or a standard uniform. The primary outcomes were insertion time, number of laryngoscopy attempts, and first-pass success rates for each device with or without donning PPE. RESULTS: In the Macintosh group, significantly less time was needed for the first successful intubation without PPE vs. with PPE (12.17 ± 3.69 s vs. 24.07 ± 5.09 s, respectively; p < 0.0001). On the other hand, such difference was not observed in the video laryngoscope group (14.99 ± 3.01 s vs. 14.01 ± 3.35 s, respectively; p = 0.07). With PPE, the first-pass success rate was significantly higher in the video laryngoscope group [41 (58.6%) vs. 66 (94.3%), p < 0.001]. The use of the video laryngoscope resulted in a significant decrease in insertion time compared with the Macintosh blade (14.01 ± 3.35 s vs. 24.07 ± 5.09 s, respectively; p < 0.0001). CONCLUSION: First-pass success and insertion time with the video laryngoscope were not affected by PPE donning. However, both were negatively affected with the Macintosh laryngoscope.

General Anesthesia Practices During the COVID-19 Pandemic in Turkey: A Cohort Study With a National Survey.

Introduction This study aimed to examine the anesthesia practices applied to the cases during the pandemic, to analyze the rate of the precautions taken in emergency/elective operations in non-COVID patients, what precautions were taken, what resources the clinics had, and the patient management in the perioperative period by organizing a survey among anesthesiologist in Turkey. Methods After obtaining approval from the Turkish Ministry of Health (2020-05-04T09_30_03) and the local ethics committee (GOKAEK-2020/10.09), a survey consisting of 21 questions was formed over the online survey inquiry (surveymonkey.com). The survey was conducted in Turkish. Results The survey aimed at reaching the anesthesiologists, who were Turkish Anesthesiology and Reanimation Society (TARD) members, by e-mail, and it was seen that 120 people out of approximately 2700 members who had received our e-mail participated in the survey. After the first case was reported in our country, it was understood that 62.1% of the participants stopped accepting elective cases in their institutions. The anesthesia method preferred in this period was general anesthesia by 47.6%, regional anesthesia by 52.1%, and sedation by 0.3%. The arrival time of coronavirus disease COVID-19 tests (PCR and/or rapid diagnostic kits showing antibodies) to the hospital was questioned; seven people (5.83%) stated that tests were not performed at their hospitals. It was observed that tests arrived and were applied at the hospitals of the remaining participants in an average of 2.7 ± 1.6 weeks. It was determined that 59.32% of the participants avoided positive pressure ventilation after induction, 5.98% of the intubation on the patients were performed by anesthesia technicians, 66.67% by anesthesiologists, 25.64% by senior resident doctors with at least two years of experience, and 1.71% by junior anesthesia assistants with less than two years of experience. The use of personal protective equipment (PPE) is applied by 95% of the participants. 22.69% of the participants stated that they preferred to use supraglottic airway (SGA) devices during this period. While 45.06% of the participants stated that they provided oxygen support to the patient with the mask belonging to the circuit after extubation, 14.8% preferred the nasal cannula, and 33.1% used an oxygen mask. Our results showed that 90% of additional precautions were taken in our country's clinics, and 95% of PPE was used. Also, the use of video laryngoscope (VL) was 75% in this period. Finally, it was found that 50.85% of the patients were taken to the recovery unit after being extubated, and 49.15% were sent directly to the service. Conclusion We can reveal that each clinic made arrangements according to its own conditions. We think that plans should be made to standardize clinical facilities and algorithms throughout the country. Apart from technological and financial facilities, we believe that the continuity of the training organized by national and international associations should be ensured so that anesthesiologists' knowledge, skills, and experience who manage this process can remain at the highest level.