The prediction of difficult intubation in obese patients using mirror indirect laryngoscopy: A prospective pilot study.

BACKGROUND: The incidence of difficult laryngoscopy and intubation in obese patients is higher than in the general population. Classical predictors of difficult laryngoscopy and intubation have been shown to be unreliable. We prospectively evaluated indirect mirror laryngoscopy as a predictor of difficult laryngoscopy in obese patients. MATERIALS AND METHODS: 60 patients with a body mass index (BMI) greater than 30, scheduled to undergo general anesthesia, were enrolled. Indirect mirror laryngoscopy was performed and was graded 1-4 according to Cormack and Lehane. A view of grade 3-4 was classified as predicting difficult laryngoscopy. Additional assessments for comparison were the Samsoon and Young modification of the Mallampati airway classification, Wilson Risk Sum Score, neck circumference, and BMI. The view obtained upon direct laryngoscopy after induction of general anesthesia was classified according to Cormack and Lehane as grade 1-4. RESULTS: Sixty patients met the inclusion criteria; however, 8 (13.3%) patients had an excessive gag reflex, and examination of the larynx was not possible. 15.4% of patients who underwent direct laryngoscopy had a Cormack and Lehane grade 3 or 4 view and were classified as difficult. Mirror laryngoscopy had a tendency toward statistical significance in predicting difficult laryngoscopy in these patients. CONCLUSIONS: This study is consistent with previous studies, which have demonstrated that no one individual traditional test has proven to be adequate in predicting difficult airways in the obese population. However, the new application of an old test - indirect mirror laryngoscopy - could be a useful additional test to predict difficult laryngoscopy in obese patients.

A survey of airway training among U.S. and Canadian anesthesiology residency programs.

STUDY OBJECTIVE: To determine the current trends in airway education in academic programs. DESIGN: Survey instrument. SETTING: American academic medical center. SUBJECTS: 147 directors of American and Canadian anesthesiology residency programs. MEASUREMENTS: An invitation to complete an online questionnaire was sent. Non-responding institutions were contacted repeatedly by email and telephone to ensure a reasonable response rate. MAIN RESULTS: 88 of the 147 (60%) programs completed the survey. Forty-three respondents (49%) reported that they had formal airway rotations, and 39 respondents said that a designated titled faculty member was responsible for airway training. Didactic lecture and manikin instruction were used by more than two thirds of the programs. Documentation of supervised airway experience was recorded in 71 (82%) programs. The majority of the programs (81%) had videolaryngoscopes. A fiberoptic bronchoscope was nearly universally available, and approximately one third (34%) of graduating residents were estimated to have performed more than 25 awake fiberoptic intubations. For most techniques, the estimates of the required number of procedures to ensure competence varied widely. CONCLUSIONS: The number of programs with a formal airway management program continues to increase, and programs are incorporating newer intubation techniques. The criteria for competence have not been established.

A proposed classification of simulators.

This paper provides a coherent and comprehensive classification of simulators, using a five letter coding system, and is based on the characteristics of the user interface and the logic controller.

Review of video laryngoscopy and rigid fiberoptic laryngoscopy.

PURPOSE OF REVIEW: Recent advances in fiberoptic systems and video technology have resulted in the development of new intubation devices and techniques. A defining characteristic of rigid fiberoptic and videolaryngoscopic techniques is that glottic opening is viewed indirectly in place of direct line-of-sight. Various issues common to all instruments in this group are highlighted, and a few recently released tools are described. The aim of this article is to review material published since January 2007. RECENT FINDINGS: Indirect laryngoscopic techniques seemed to be easy to learn by both novice and experienced intubators, and can be used to teach both direct laryngoscopy and fiberoptic intubation. An adequate glottic view is generally easily obtained, which is frequently superior to that obtained by direct laryngoscopy. However, endotracheal tube insertion may be problematic, and various techniques have been developed to facilitate this procedure. Indirect laryngoscopic techniques are proving useful in situations of both anticipated and unanticipated difficult intubations, and therefore challenge the preeminence of flexible fiberoptic intubation. SUMMARY: As indirect laryngoscopic tools become more available, and clinicians become more facile in their use, the management of (potentially) difficult intubations is likely to change. Further technological advances are likely to lead to the development of even more new instruments.

Teaching without a teacher: developing competence with a Bullard laryngoscope using only a structured self-learning course and practicing on a mannequin.

STUDY OBJECTIVE: To show that a complex motor skill can be taught without requiring active expert faculty participation. DESIGN: Prospective descriptive study. SETTING: Simulation laboratory of an academic anesthesiology department. SUBJECTS: Novice users of the Bullard laryngoscope, predominantly residents. INTERVENTIONS: Novice Bullard users were presented with a PowerPoint presentation using text and pictures describing the use of the Bullard. The learners were also provided with a Bullard laryngoscope and a mannequin on which to practice. Self-learning time was not restricted. MEASUREMENTS: Learners decided for themselves when they were competent and ready for competency assessment. The assessment tool was a checklist of essential steps developed by faculty experienced in Bullard laryngoscopy. The primary end-point was successful intubation. MAIN RESULTS: All learners were deemed competent. The mean self-learning time was 14.1 minutes (SD, 3.1 min; range, 9.2-21.0 min). All subjects indicated a high level of satisfaction with the learning technique. CONCLUSIONS: Teaching a complex motor skill with no expert instruction is possible.