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Efficacy of a combined technique using the Trachlight^TM together with direct laryngoscopy under simulated difficult airway conditions in 350 anesthetized patients

Rome, Italy

To the Editor:

Difficulty in airway management is the most important cause of anesthesia related morbidity and mortality.¹ This investigation aimed to evaluate the efficacy of the Trachlight^TM (TL), used in conjunction with direct laryngoscopy (DL), for intubation in patients under simulated difficult airway conditions.

After obtaining Ethical Committee approval and informed written consent, 350 ASA I–II surgical patients (female/male: 181/169), aged 47.3 ± 15.7 yr, without evidence of difficult intubation were enrolled. Patients affected by gastroesophageal reflux, asthma, obesity, and hiatus hernia were excluded.

DL was performed by anesthesiologists with greater than five years of clinical experience. Allowing the epiglottis to fall back and obscure the view of the cords simulated a Cormack grade 3 laryngoscopic view. Under DL, the TL was passed underneath the epiglottis. When an optimal transillumination was obtained,² tracheal intubation (TI) was achieved. If transillumination was not adequate,² the procedure was tried again. Only one additional manoeuver (partial TL withdrawal and repositioning; TL alignment on the midline; neck flexion; external cricoid pressure) was permitted during a single attempt. A total of three attempts at TI were allowed.

Duration of intubation was defined as the time from the introduction of the laryngoscope in the mouth to the first positive capnography, excluding the time between two consecutive attempts. An independent observer recorded the duration, number of attempts, difficulties and complications of intubation.

The success rate after the first attempt at TI was 78% (273/350), with a mean duration of intubation of 11.8 ± 2.3 sec. In an additional 16% of patients (56/350) TI was successful after the second attempt (total success = 94%): a faint glow was seen on the first attempt, but no additional manoeuver was able to redirect the tip of the TL correctly so that a second attempt was needed (duration of intubation 27.3 ± 2.1 sec). In an additional 6.0% of patients (21/350), TI required a third attempt (total success = 100%; duration of intubation 38.1 ± 3.3 sec). No esophageal intubations were recorded.

The high rate (78%) of successful TI at the first attempt suggests that the TL may be a reliable adjunct for airway management in patients presenting a grade 3 Cormack view at DL.³ In 16% of patients a second attempt was needed. In some patients, the angle of the lighted stylet was lost due to retraction of the inner stylet during the first intubation attempt. It is crucial to verify that the TL is prepared correctly and remains in this condition between attempts.² In 6% of patients a third attempt was needed, essentially because of difficulties in advancing the endotracheal tube (ET) in the trachea after withdrawal of the inner stylet. Retracting the stylet directs the ET upward and anteriorly and we think that the difficulties encountered could, possibly, be due to contact between the ET and the anterior laryngeal wall. Flexing the patient's head can help solve such difficulties.

No esophageal intubation occurred. We believe this is due to the meticulous attention paid to optimal transillumination before attempting to intubate the trachea.

In conclusion, we suggest that the use of the TL together with DL may be another useful alternative in the management of unanticipated difficult intubations.

References

1 Cheney FW. The American Society of Anesthesiologists Closed Claims Project: what have we learned, how has it affected practice, and how will it affect practice in the future? Anesthesiology 1999; 91: 552–6.[Medline]

2 Agrò F, Hung OR, Cataldo R, Carassiti M, Gherardi S. Lightwand intubation using the Trachlight^TM: a brief review of current knowledge. Can J Anesth 2001; 48: 592–9.[Abstract/Free Full Text]

3 Benumof JL. The American Society of Anesthesiologists' management of the difficult airway algorithm and explanation-analysis of the algorithm. In: Benumof JL (Ed). Airway Management. Principle and Practice. St. Louis, Missouri: Mosby, 1996: 143–56.

This article has been cited by other articles:

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