Prospective validation of a new airway management algorithm and predictive features of intubation difficulty

Abstract

Background: Some patients have features that indicate possible difficulty with direct laryngoscopy for tracheal intubation. Prediction of the likely outcome and selection of patients for an enhanced management algorithm would reduce the possible harm from failed intubation attempts. Methods: Adult elective patients were assessed for seven features associated with difficult direct laryngoscopy, ranked in difficulty from 0 to 3. For a patient with at least one Class 3 feature, or two or more features of class 1 or higher, the enhanced management used a channelled videolaryngoscope Airtraq™ instead of a Macintosh laryngoscope. A long flexible angulated stylet and a flexible fibrescope would be used as the second and third steps. For patients with lesser difficulty scores, a Macintosh laryngoscope was used. Outcomes of enhanced management were analysed. Logistic regression and Random Forest algorithm, using the ranks of the predictive features, were used to predict difficulty during enhanced management. Results: We prospectively studied 16 695 patients. We selected 1501 (9%) for enhanced management, and tracheal intubation was successful in all of them. Of these, 73% were intubated in less than 30 s, and only 4.5% required more than 4 min for intubation. Progression to the second and third steps of enhanced management was predicted by restriction of mouth opening and reduced cervical spine mobility. Conclusions: An enhanced management algorithm allowed successful tracheal intubation of all patients with anticipated difficult laryngoscopy. The need to combine the use of a stylet and a fibrescope with the Airtraq™ could be predicted with a high degree of certainty.

Difficult airway management algorithms: a directed review

“…The Vortex was the most commonly referred to non‐society algorithm (n = 4, 7%) . The study methodology in the majority of articles was observational (n = 28, 51%) , with 18 (33%) being opinion articles or editorials . Five papers were reviews of published airway algorithms and four were interventional studies, including three randomised controlled trials .…”

“…Of these, 44 (80%) focused solely on society‐produced algorithms . Five focused on non‐society‐produced algorithms and six included both in their analysis . Five of these articles also served as publications for a total of seven algorithms .…”

Recent advances in laryngoscopy in adults

“…A French group evaluated a new algorithm for elective airway management in the operating room 12 . Patients presenting features predictive of a difficult (direct) laryngoscopy received an “enhanced management” strategy that used a channeled optical laryngoscope (Airtraq, Vygon, Écouen, France; the Airtraq is operationally similar to a VL but uses prisms rather than a video camera to provide its view) as a first step in conjunction with a long flexible angulated stylet (Frova Intubating Introducer, Cook Medical, Bloomington, IN, USA) and a flexible videoendoscope (aScope 3™, Ambu, Ballerup, Denmark) as the second and third steps, respectively.…”

“…Patients presenting features predictive of a difficult (direct) laryngoscopy received an “enhanced management” strategy that used a channeled optical laryngoscope (Airtraq, Vygon, Écouen, France; the Airtraq is operationally similar to a VL but uses prisms rather than a video camera to provide its view) as a first step in conjunction with a long flexible angulated stylet (Frova Intubating Introducer, Cook Medical, Bloomington, IN, USA) and a flexible videoendoscope (aScope 3™, Ambu, Ballerup, Denmark) as the second and third steps, respectively. This approach prospectively studied 16,695 patients, achieving successful tracheal intubation of all patients with anticipated difficult laryngoscopy 12 . The stratification also resulted in relatively few patients with poor laryngeal views, requiring multiple attempts, or experiencing oxygen desaturation.…”

Clinical Approach to the Patient in Critical State Following Immunotherapy and/or Stem Cell Transplantation: Guideline for the On-Call Physician

“…Step 2 is A—Airway check of the patency of the airway. The physician can use chin lift and head tilt, or jaw thrust as airway opening maneuvers, and inspect the oropharynx for foreign bodies [29,30]. If the airway is clear and the patient is not breathing, step 3 is calling of the emergency team and starting basic life support (BLS).…”