The document summarizes a comparative study that evaluated the McGrath video laryngoscope, Airtraq optical laryngoscope, and Macintosh laryngoscope for intubating patients with simulated difficult airways using neck collars. It found that the McGrath and Airtraq devices resulted in better glottic views, fewer intubation attempts, lower intubation difficulty scores, and shorter intubation times compared to the Macintosh laryngoscope. The document concludes that the McGrath and Airtraq are safer and more effective alternatives to the Macintosh for intubating patients with immobilized necks.

3. Airway Management:
A Comparative Study Using
McGrath® Video
laryngoscope versus
Airtraq® and Macintosh
Laryngoscope in Neutral
Position.

4. Presented by
Alaa Elsayed Goma Falogy
M.Sc. Assistant lecturer of Anaesthesia and
Surgical Intensive care
Faculty of medicine
Zagazig University

5. Under supervision of
Prof. Dr. Ayman Abdel El-Salam Hassan
Professor of Anesthesia and surgical Intensive Care
Prof. Dr. Ahmed Abd El-Hakim Balata
Professor of Anesthesia and surgical Intensive Care
Prof. Dr. Khaled Mohammed El-Sayed
Professor of Anesthesia and surgical Intensive Care

6. I would like to thank….
Prof, Dr.: Salah A. Fattah Ismail
For his sincere effort to travel all
this distance to give us this honor
to be with us this special day

7. I would like to thank….
Prof, Dr.: Ahmed M. Salama
For his pleased acceptance to share
us this discussion

8. I would like to thank….
to my precious family;
you mean the world to me
you'll always be my strength, my power,
thank you for being a part of me...

9. Research question
If
used by [experienced anesthiologists] who is
managing a model of a difficult airway in form of
neck immobilization by semi- rigid neck collar
Do [ the Airtraq OL and the McGrath VL]
Are
more safe and more effective in tracheal intubation
when compared to [Classic Macintosh
laryngoscope]?

10. Introductio
n

11. • Airway management is a major challenge
for the anaesthesiologists in their everyday
operative practice using direct
laryngoscopy.
• During this direct laryngoscopy, positioning
of the head and neck in neutral position
• will decrease chance of optimal laryngeal
visualization which impair the line of sight
between laryngeal , pharyngeal and oral
axes.

12. Concept of line of sight during
direct laryngoscopy

13. • patients with cervical spine instability who
necessitate neck immobilization , airway
management implies upon a high risk of
neurological damage related to head and neck
manipulation, so semi-rigid neck collar is
applied in trail to control neck movement.
• Such immobilisation technique can turn
intubation process under the direct
laryngoscopy into more difficult situation
(Impair the line of sight) .

14. • These concerns have aroused the idea to develop
number of alternatives to classical Macintosh
laryngoscope such as Airtraq® Optical
Laryngoscope, McGrath® Video laryngoscope.
• These laryngoscopes do not require the
arrangement of pharyngeal, laryngeal and oral
axis in one line of sight and thus do not require
modulation of neutral position.
• During difficult airway situations, both Airtraq
optical laryngoscope and McGrath Video
laryngoscope sound to be better than Macintosh
laryngoscope

15. in stimulated difficult intubation
situations
in patients with their cervical spine kept
in neutral position
by semi-rigid neck collar as an
immobilization techniques.
VS

16. NECK
EXTENSION

17. Cervical spine stability
 Cervical stability:
 is the ability of the
spine to maintain
strong relationships
between vertebrae,
so as not to
damage the neural
structures contained
within the spinal
column
Cervical instability:
Excess translational
or rotational motion
of any vertebra and
means that the
odontoid process is
no longer firmly
held against the
back of the anterior
arch of C1.

18. Concept of
Videolaryngoscopy Video laryngoscopy (VL) is an
update of high resolution
micro-cameras systems that
improves the success rate of
intubation.
 There is a hypothesis that
improved lighting and a better
view can increase the chance
of intubation success.
 Anaesthesia had used the
miniature camera for many
years but for only bronchial
endoscopy .

19. Video Laryngoscopy in difficult
Airway management
VIDEO ASSISTED
LARYNGOSCOPY
AS AN INTIAL
APPROACH TO
INTUBATION

20. McGrath
Video-
Laryngoscope

21. The McGrath Video Laryngoscope:
(Aircraft Medical, Edinburgh, United
Kingdom)
• A video-based system for tracheal intubation
that utilizes a video camera embedded into a
camera stick.
• The unit is a battery powered Features a
single electronic control
• Offers the user an image of the Glottis and
the surrounding anatomy on a LCD screen.
• The unit which is used as a part of much the
same way as common as Macintosh
laryngoscope

22. Concept of the improved glottic
view
Based upon the hypothesis that improved glottic view
leads the better chance of successful intubation

23. Airtraq
Optical-Laryngoscope

24.  based on refraction prism principle to give an angular
view of the glottic area.
 The blade of the Airtraq consists of two side by side
channels.
 One channel act as housing for the ETT, and the other
channel terminates in terminal lenses and transmit back
the image.
 The viewed image is then been transmitted to a proximal
eye piece viewfinder employing a prisms system and lenses
not as basic concepts of usual fiberoptics.
AIRTRAQ Optical Laryngoscope:

25. PATIENTS
AND
METHODS

26. METHODOLOGY
 This was a prospective, randomized clinical trial.
 group assignments (C, A and M)
 age group of 20-50 years, ASAps Grades I or II
undergoing elective surgery requiring general
Anaesthesia
 three groups of 50 patients each , of either sex.
 All patients received standard monitoring
according to ASA guidelines.

27. INTUBATION PROCEDURE
 Intubation process was performed by one
anesthesiologist with accepted experience in two
recent video laryngoscopes under study.
 A malleable stylet was used in both groups
(Classical Macintosh and McGrath VL).
 The technique was considered failed if tracheal
intubation was not achieved within 120 seconds
or within a maximum of three intubation
attempts.

28. CORMACK - LEHANE SCORE

29. INTUBATION PROCEDURE
 Intubation time was separated into T1 and T2.
T1 is the time between insertions of the allocated
laryngoscope in the mouth until optimal glottic view
including optimization maneuvers.
T2 is the time from optimal glottic view till
confirmation of tracheal intubation (by vision)
including removal of the device.

30. McGrath VL;
INTUBATION TECHNIQUE AND
SEQUENCE

31. Intubation sequence by McGrath VL
 With the patient in neutral position, use left hand to
introduce the VL into the midline of the oropharynx.
 Push the blade tip till it past the posterior portion of the
tongue.
 Then turn eyes to the video screen in order to obtain the
best view of the glottis.
 The video image of the glottis now is representing
Cormack – Lehane view.
 Using LCD screen, the ETT is then advanced on a
smooth curve through the glottis mediated by stylet.

32. Intubation sequence by McGrath VL
introduce the VL into the
midline of mouth and Push the
blade tip till posterior portion
of the tongue.

33. Intubation sequence by McGrath VL
turn eyes to the
video screen in
order to obtain
the best
Cormack –
Lehane view.

34. Intubation sequence by McGrath VL
By use of
LCD screen,
the ETT is
then advanced
on a smooth
curve through
the glottis by
stylet.

35. AIRTRAQ OL;
INTUBATION TECHNIQUE
AND
SEQUENCE

36. Intubation sequence by Airtraq OL
 Add lubricant to outer surface of the
endotracheal tube and hosting channel of
Airtraq OL.
 Embed the tube into the side holding channel of
the Airtraq so that the tip of the endotracheal
tube is at the tip of the side channel.
 Turn on the light for about 30-60 seconds
before the procedure.

37. Intubation sequence by Airtraq OL
 The device is held in the mouth in the midline
by right hand .
 Then advanced by sliding over the tongue.
 The image on view finder is optimized by
moving the blade as necessary by left hand.
 The laryngeal inlet must be in the centre of
viewfinder just before pushing the ETT forward
by right hand .

38. Intubation sequence by Airtraq OL
Loading ETT
to hosting
channel
Introduction
into oral cavity

39. Intubation sequence by Airtraq OL
Sliding over the
tongue
Checking the
viewfinder and
ETT insertion

40. Intubation sequence by Airtraq OL
Unholding the ETT
from the Airtraq
Removal of the
Airtraq

41. RESULTS

42. PARAMETERS TO BE COMPARED
BETWEEN ALL GROUPS
 Demographic data and Airway assessment data.
 Intubation Conditions:
 Numbers of Attempts.
 Optimization Procedures.
 Cormack - Lehane score.
 Intubation Difficulty Score.
 Success Rate of Intubation.
 Time To Intubation.
 Hemodynamics (HR and MAP).
 Complications.

43. DEMOGRAPHIC AND
AIRWAY ASSESSMENT DATA
Demographic data Group C Group A Group M
p-value (Sig.)
(N=50) (N=50) (N=50)
Age (in years) 35.90±7.65 35.92±7.70 35.16±7.72 0.856** (NS)
Male / Female 62 / 38 % 66 / 34 % 60 / 40 % 0.892* (NS)
Height (cm) 171.48±3.71 171.62±3.54 171.6±3.8 0.981** (NS)
Weight (Kg) 77.96±7.22 77.62±6.25 76.86±6.93 0.619** (NS)
BMI (Kg/m2
) 26.84±2.29 27.06±2.05 26.14±2.13 0.095** (NS)
ASAps I / II 14 / 86 % 16 / 84 % 10/ 90 % 0.668* (NS)
MS I / II 56 / 44 % 48 / 52 % 62 / 38 % 0.369* (NS)
TMD (cm) 7.18±0.34 7.12±0.34 7.17±0.32 0.766** (NS)
NON-
SIGNIFICANT

44. NUMBERS OF ATTEMPTS
Macintosh group Airtraq group McGrath group
Most of patients in VL need 1 attempt
for successful intubation
About 1/3 patients needed 2nd and 3rd attempt in
Macintosh group
HS

45. OPTIMIZATION PROCEDURE
Highly Significant

46. CORMACK-LEHANE SCORE
46
Airtraq almost get C&L I
MacintoshleastinC&LI
PERSIST
Most views of McGrath C&L II
Macintosh most C&L II
HIGHLY-
SIGNIFICANT

47. IDS DISTRIBUTION
AirtraqmaxIDSis2
McGrathmaxIDSis4
MacintoshreachedIDS7
HIGHLY-
SIGNIFICANT

48. SUCCESS RATE OF INTUBATION
Macintoshhas4failures
NON-
SIGNIFICANT

49. SAFETY AND EFFECTIVENESS
INTER-GROUP ANALYSIS
49
BETTER
IMAGE CONCEPT
THOERY
SAME
VIDEOSCOPE
EFFIENCY
FAMILARITYNO NEED FOR
ALIGNMENT

50. AIRTRAQ
LEAST
MACINTOSH
MOST
HEMODYNAMICS (HR)
NON-
SIGNIFICANT
HS
HIGHSIGNIFICANT
HIGHSIGNIFICANT

51. ALL Increased MAP
ALL return to basal level
HEMODYNAMICS (MAP)
NON-
SIGNIFICANT

52. Time to Intubation
52
Familiarity and
same technique
HIGH
SIGNIFICANT
3 2 1
3 1 2

53. Complications
Sharp tip for
both devices
produce
more trauma
as primary
insult more
than
secondary
injury
Stylet
manipulation??
Primary > secondary
Secondary is more
than primary

54. LIMITATIONS
DESIGN
Operator knows the devices, which may also introduce bias.
(solved by closed envelopes basis (lottery technique)).
STIMULATIVE
Not on real cervical trauma patients.
FURTHERMORE,
Inter-incisor distance may be added in airway assessment
parameters as pre and post insertion of neck collar especially
because it affects primary insertion of Airtraq OL.

55. SUMMARY
AND
CONCLUSION

56. Research question
Are McGrath® Video
laryngoscope versus Airtraq more
safe and more effective in
tracheal intubation when
compared to Classic Macintosh
laryngoscope in patients with
neck collar inserted?

57. Airtraq OL and McGrath VL
showed the prove beyond doubt
to be safer and more effective
than Macintosh Laryngoscope in
managing stimulated difficult
intubation situation in form of
cervical spine immobilization.

58. RECOMMENDATIONS

59. The use of videolaryngoscopes in
our daily practice is recommended
specially in difficult airway
scenarios and similar studies need
to be done upon real cervical
trauma patients for better
assessment of its advantages and
disadvantages.

60. THANK YOU