Esophageal Guidewire-Assisted Nasogastric Tube Insertion in Anesthetized and Intubated Patients

Abstract

D ifficult and failed tracheal intubations are one of the principal causes of anesthetic-related mortality and morbidity. Difficult intubations are common in obese patients because the limited oropharyngeal space may impede adequate visualization. With the increase in numbers of obese and morbidly obese patients, the incidence of difficult intubations is also likely to rise. The Pentax AWS (Ambu A/S, Ballerup, Denmark) is a video laryngoscope designed to facilitate intubation by providing a video image of the glottis. It has a miniature video camera and a battery-powered, built-in liquid crystal display monitor, which allows a simultaneous view of the glottis with insertion of the endotracheal tube. Reports suggest that this device can help with intubation, but randomized data are lacking. This study compared intubation in obese patients using the Pentax AWS or the standard Macintosh laryngoscope with a no. 4 blade.Patients (n = 105) with a body mass index between 30 and 50 kg/m 2 were randomly allocated to intubation using either a conventional Macintosh laryngoscope no. 4 blade (Macintosh group) or the Pentax AWS (Pentax group). For the Pentax group, the device was placed into the patient's mouth and advanced into the posterior pharynx in the midline until the cross-hair target symbol was centered on the glottic aperture. The endotracheal tube was then advanced toward the trachea. The glottic view for each laryngoscopy was graded using the Cormack-Lehane grading system, and the ease of intubation was graded on a Likert scale (0 = extremely easy to 100 = extremely difficult). The presence of any blood staining and the severity of postoperative sore throat were assessed. Intubation success rate, time and ease of intubation, and occurrence of complications were recorded.Data from 99 patients were analyzed. Median time to intubation was 38 seconds with the Pentax AWS and 26 seconds with the Macintosh. Intubations using the Pentax device were also slower than the Macintosh laryngoscope after adjusting for American Society of Anesthesiologists physical status and Mallampati score. The 2 groups did not differ in the number of attempts, successful intubation on the first attempt (Pentax 86% vs Macintosh 92%); these rates increased to 90% and 100%, respectively, on a second attempt. For patients who needed a third attempt, the intubation was considered unsuccessful. The difficulty of tracheal intubation was worse in the Pentax group compared with the Macintosh group. When the Cormack-Lehane scores of 1 and 2 were considered good and those of 3 and 4 were considered not good, the groups did not differ. The view was good in 86% of patients in the Pentax group. The groups did not differ in bleeding nor in severity of sore throat. These results suggest that the Pentax AWS should not be routinely substituted for the conventional Macintosh no. 4 blade in morbidly obese patients.

Nasogastric tube insertion in intubated patients with the guide of wire rope: A prospective randomised controlled study

“…Kirtania et al observed higher rate of successful NGT insertion in esophageal guide wire-assisted Technique compare to conventional technique (99.2% vs 56.7%). 11 The success rates of NGT insertion in the first attempt in our study was 98%. This difference may be due to sample of patients in Kirtania study which was much larger than ours.…”

Comparison of different methods of nasogastric tube insertion in anesthetized and intubated patients: A meta-analysis

“…Appukutty et al [ 17 ] compared a slit endotracheal tube and guidewire with the conventional method and showed similar success rates. Kirtania et al [ 23 ] showed that the esophageal guidewire-guided technique with a manual shift of the larynx resulted in correct NGT placement in anesthetized patients and had a low incidence of complications and comparatively shorter insertion times.…”

The GlideScope with modified Magill forceps facilitates nasogastric tube insertion in anesthetized patients: A randomized clinical study

“…These attempts include the use of slit endotracheal tubes, forward displacement of the larynx, use of various forceps, use of a ureteral guidewire as a stylet, head flexion, and lateral neck pressure. [2][3][4][5] Visualization-aided modalities were recently developed to facilitate NGT insertion, 1,6 and studies have been performed to examine the role of modified Magill forceps, which have angles similar to those of the GlideScope blade (Verathon, Bothell, WA, USA) (Figure 1). 7 The purpose of this study was to investigate whether the GlideScope and modified Magill forceps facilitate NGT insertion in patients under general anesthesia who have undergone endotracheal tube insertion.…”