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3/1/2014
1
Dennis Spence PhD, CRNA
http://www.bing.com/images/search?q=images+of+difficult+airway&qs=n&form=QBIR&pq=images+of+difficult+airway&sc=6 -19&sp=-
1&sk=
Disclaimer The views expressed in this presentation are those of
the author and do not reflect official policy or position of the Department of the Navy, the Department of Defense, the Uniformed Services University of the Health Sciences, or the United States Government.
The author does not endorse, promote or advertise any products presented in this presentation.
Disclosure Nothing to disclose
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Objectives Review the ASA Difficult Airway Algorithm and
Airway Approach Algorithm
Describe components of the preoperative airway assessment
Discuss current evidence as it relates difficult airway management
Describe how to prepare for a difficult intubation
Review the various equipment/alternative airway devices and methods used for management of the DA
Clinical Vignette 67 y/o male presents
with angioedema tongue
PMH- HTN 15 yrs, high cholesterol
Meds- lisinopril, zocor
How would you manage this airway?
Difficult Airway Management Is the approach to the
difficult airway changing?
Is the direct laryngoscope going the way of the rotary telephone?
What about the Awake Fiberoptic Intubation (AFOB)?
Do new graduates know how to do an AFOB?
Spence DL. Anesthesia Abstracts. 2010.4(12): 1-34.
http://www.bing.com/images/search?q=images+of+difficult+airway&qs=n&form=QBIR&pq=images+of+difficult+airway&sc=6-19&sp=-1&sk=
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ASA Difficult Airway Algorithm 2013
Apfelbaum HL et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118.
Updated evidence and findings from surveys
No major changes
Changes some terms used
Expands step 1 assessment of potential difficulties
Addition of video-assisted laryngoscopy to algorithm
ASA Difficult Airway Algorithm 2013
Apfelbaum HL et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118.
ASA Difficult Airway Algorithm 2013
Apfelbaum HL et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118.
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ASA Difficult Airway Algorithm 2013
Apfelbaum HL et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118.
The Airway Approach Algorithm
Rosenblatt W H , Whipple J Anesth Analg 2003;96:1233-
1233
©2003 by Lippincott Williams & Wilkins
ASA Difficult Airway Algorithm Skeleton
WAKE-UP?
HELP!!!
Call for Help
Rosenblatt W H , Whipple J. The Difficult Airway Algorithm of the American Society of Anesthesiologists. Anesth Analg 2003;96:1233-1233.
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Preoperative Airway Exam
http://www.bing.com/images/search?q=images+preoperative+airway+examination&qs=n&form=QBIR&pq=images+preoperative+airway+examination&sc=0-14&sp=-1&sk= Dr Benumof Airway lecture
Airway Exam Airway Exam Component Abnormal Finding
1. Length of upper incisors Relatively long
2. Relation of maxillary and mandibular incisors during normal jaw closure
Prominent “overbite”
3. Relation of maxillary and mandibular incisors during voluntary protrusion of mandible
Cannot bring mandibular incisors anterior to maxillary incisors
4. Interincisor distance < 3 cm
5. Visibility of uvula Not visible when tongue is protruded with patient in sitting position e.g., Mallampati class > II)
6. Shape of palate Highly arched or very narrow
Airway Exam Airway Exam Component Abnormal Finding
7. Compliance of mandibular space
Stiff, indurated, occupied by mass, or nonresilient
8. Thyromental distance <3 ordinary finger breaths
9. Length of neck Short
10. Thickness of neck Thick (>40-42 cm)
11. Range of motion of head and neck Patient cannot touch tip of
chin to chest or cannot extend neck
Other findings/predictors of DA: Obesity, OSA, AHI≥30
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Mallampati Score
http://www.bing.com/images/search?q=images+preoperative+airway+examination&qs=n&form=QBIR&pq=images+preoperative+airway+examination&sc=0-14&sp=-1&sk=
http://www.bing.com/images/search?q=images+preoperative+airway+examination&qs=n&form=QBIR&pq=images+preoperative+airway+examination&sc=0-14&sp=-1&sk=
Submandibular & Submental Abscesses
http://www.bing.com/images/search?q=images+preoperative+airway+examination&qs=n&form=QBIR&pq=images+preoperative+airway+examination&sc=0-14&sp=-1&sk=
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Severe Retrognathia
http://www.bing.com/images/search?q=images+preoperative+airway+examination&qs=n&form=QBIR&pq=images+preoperative+airway+examination&sc=0-14&sp=-1&sk=
Rosenblatt W et al. Anesth Analg 2011;112:602-607
©2011 by Lippincott Williams & Wilkins
What about upper airway pathology?
Preoperative Endoscopic Airway Exam (PEAE)
In patients with upper airway pathology does a performance of a PEAE change the plan?
Asleep Intubations = 83% Majority intubated asleep • asleep asleep = 62% • awake asleep = 20%
• FOB = 43% • DL/VL = 56% • N = 1 retrograde wire
Awake Intubation = 24% • awake awake = 12% • asleep awake = 6% Conclusion: PEAE may ID pts with upper airway pathology who truly need AFOB
Rosenblatt WH et al. Preoperative Endoscopic Airway Examination (PEAE) provides superior airway information and may reduce the use of unnecessary awake intubation. Anesth Analg 2011;112:602–7 Spence D. Anesthesia Abstracts 2011;(5)3:3-7.
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Do the same predictors of difficult intubation apply to
indirect video laryngoscopy?
Predictors of Difficult Airway with the GlideScope©
Tremblay et al. Poor visualization during direct laryngoscopy and high upper lip bite test score are predictors of difficult intubation with the GlideScope® videolaryngoscope. Anesth Analg 2008;10(6): 1495–1500.
Time to Intubate
• Poorer glottic view on DL:
• r = .273
• Higher upper lip bit test score:
• r = 250
• Short sternothyriod distance:
• r = - .146
• Most difficulties due to difficulty navigating ETT into glottis
Weak correlations
Predictors of Difficult Airway with the GlideScope©
1st Attempt Success and Mallampati Class
MP class not predictive of DI
Other risk factors not individually predictive
Díaz-Gómez JL, Satyapriya A, Satyapriya SV, et al. Standard clinical risk factors for difficult laryngoscopy are not independent predictors of intubation success with the GlideScope. J Clin Anesth. 2011;23(8):603-610.
1st Attempt Success
MP I or II MP III or IV0
20
40
60
80
10088%
83%
N = 357P = NS
pe
rce
nta
ge
of
pa
tie
nts
(%
)
96% intubated ≤3 attempts
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Important Question: Can I ventilate the patient?
http://www.bing.com/images/search?q=images+mask+ventilation&qs=n&form=QBIR&pq=images+mask+ventilation&sc=0-12&sp=-1&sk=
Can I ventilate the patient?
http://www.bing.com/images/search?q=images+mask+ventilation&qs=n&form=QBIR&pq=images+mask+ventilation&sc=0-12&sp=-1&sk=
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•1 in 690 IMV
•25% were DI
•1 in 2800 IMV +DI
Predictors of Impossible Mask Ventilation (n = 77/53,041)
Predictor Odds Ratio
Neck radiation changes 7.1
Male gender 3.3
Sleep apnea 2.4
MP III or IV 2.0
Presence of beard 1.9
Kheterpal S et al. Prediction and outcomes of impossible mask ventilation: review of 50,000 anesthetics. Anesthesiology 2009;110:891-897.
• N = 176,679 DAs = DMV + DL • 2.5% DMV • 4.4% DL • 1 in 250 DMV + DL
• DMV rate lower w/NMB • 2.6% vs. 3.6%, P < 0.01
Predictors of DMV + DL
Kheterpal S et al. Incidence, predictors, and outcome of difficult mask ventilation combined with difficult laryngoscopy. Anesthesiology 2013;119:1360-9
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Airway Exam Summary Consider overall airway exam, risk of difficult
ventilation, and aspiration risk when making plan
Coexisting diseases
Further research needed on predictors of DI with indirect video laryngoscopy
Err on the side of caution and assume DI
Always consider AFOB in DI, especially w/ upper airway pathology
Positioning
What is the optimal position for intubation?
http://www.bing.com/images/search?q=images+mask+ventilation&qs=n&form=QBIR&pq=images+mask+ventilation&sc=0-12&sp=-1&sk=
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Rao Sl et al. Laryngoscopy and tracheal intubation in the head-elevated position in obese patients: a randomized, controlled, equivalence trial. Anesth Analg 2008;107:1912-1918.
Ramping the Patient
http://www.bing.com/images/search?q=images+airpal&qs=n&form=QBIR&pq=images+airpal&sc=4-13&sp=-1&sk=
DMV & Which NMB to Give?
Amathieu R et al. An algorithm for difficult airway management, modified for modern optical devices (airtraq laryngoscope; ctrach™): a 2-year prospective validation in patients for elective abdominal, gynecological, and thyriod surgery. Anesthesiology 2011;114:25-33 Spence DL. Anesthesia Abstracts 2010;(4)12: 8-13.
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Results • 99% <3 RF easy FMV • 93% >3 RF easy FMV • n = 2 IMV • DMV n = 90
• FMV improve w/ sux = 62% • Intubated 1st attempt = 98.05% • Bougie used 1st in DA = 1.7% • AirTrach 2nd = 0.19% • LMA-C use = 0.024%
Conclusion
• New algorithm successful
• More aggressive use of NMBs + backup devices contribute high success rate
http://www.bing.com/images/search?q=images+of+video+laryngoscopy&qs=n&form=QBIR&pq=images+of+video+laryngoscopy&sc=0-16&sp=-1&sk=
How to Improve Glottic View?
http://www.bing.com/images/search?q=images+BURP+manuever&qs=n&form=QBIR&pq=images+burp+manuever&sc=0-12&sp=-1&sk=
http://www.bing.com/images/search?q=images+eschman+stylet&qs=n&form=QBIR&pq=images+eschman+stylet&sc=0-11&sp=-1&sk=
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Indirect Video Laryngoscopy
http://www.bing.com/images/search?q=images+of+glidescope&FORM=AWIR
http://www.bing.com/images/search?q=images+of+video+laryngoscopy&qs=n&form=QBIR&pq=images+of+video+laryngoscopy&sc=0-16&sp=-1&sk=
Indirect Video Laryngoscopy
Does indirect video laryngoscopy improve success rate in novices?
Does the use of an indirect video laryngoscopy device improve the view in potential difficult airways?
Does the use of an indirect video laryngoscope device speed up the time to intubation? 1st attempt success in experts?
Does video laryngoscopy improve success after failed direct laryngoscopy?
What are the risk factors for failed indirect video laryngoscopy?
What are the potential complications with indirect video laryngoscopy?
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Indirect Video Laryngoscopy & Novices
Nouruzi-Sedeh P et al. Laryngoscopy via Macintosh blade versus Glidescope: success and time for endotracheal intubation in untrained medical personnel. Anesthesiology 2009;110:32-7. Spence DL. Anesthesia Abstracts 2010;(4)6: 7-9.
• N = 20 no experience • 5 intubations each device Intubation within 2 minutes Higher w/ Glidescope 93% vs. 51%, P <0.01 Time to intubation Faster w/ Glidescope 63 ± 30 s vs. 89 ± 35 s; P < 0.01
Spence DL.. Anesthesia Abstracts 2010;(4):12.
Spence DL.. Anesthesia Abstracts 2010;(4):12.
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LESS EXPERIENCE
Aziz MF, Healy D, Kheterpal S, Fu RF, Dillman D, Brambrink AM. Routine clinical practice effectiveness of the Glidescope in difficult airway management: an analysis of 2,004 Glidescope intubations, complications, and failures from two institutions. Anesthesiology. 2011;114(1):34-41.
Meta-Analysis GlideScope© vs. Direct Laryngoscopy
Glottic view (Gr I vs. ≥ Gr 2)
Anticipated or simulated DA
3.5x more likely GR I view (P < 0.05)
+publication bias
1st Intubation Success
Non-experts 1.8x more likely intubate (P <0.05)
Experts: No improvement vs. DL (P = NS)
Time to intubation
Non experts: 43 sec faster intubation(P < 0.05)
Experts: 8 sec faster intubation (P = NS)
Conclusion: Improves glottic view, especially in simulated or potential DA. May help non experts more than experts
Greisdale DE et al. Glidescope® video-laryngoscopy versus direct laryngoscopy for endotracheal intubation: a systematic review and meta-analysis. Can J Anesth. 2012; 59(1): 41–52
http://www.bing.com/images/search?q=images+of+video+laryngoscopy&qs=n&form=QBIR&pq=images+of+video+laryngoscopy&sc=0-16&sp=-1&sk=
Indirect Video Laryngoscopy Simulated difficult intubations
McGrath, Airtraq, and GlideScope© provide superior intubating conditions compared to Macintosh blade(P < 0.05)
Pentax-AWS: 99.6% of DI (MAC grade view 3-4) were grade 1-2
Pentax-AWS: rescue device success in DI = 99.3%
McGrath® Series 5: 100% success in simulated DI with in-line stabilization
Difficult intubation success rate Pentax-AWS = 100%, Glidescope = 96%, Macintosh blade = 84%
Savoldelli GL et al. Comparison of the Glidescope, the McGrath, the Airtraq, and the Macintosh laryngoscopes in simulated difficult airways. Anaesthesia, 2008, 63, 1358–1364. Taylor et al. The McGrath® Series 5 videolaryngoscope vs the Macintosh laryngoscope: a randomised, controlled trial in patients with a simulated difficult airway. Anaesthesia 2013;68: 142-47 Asai T et al. Use of the Pentax-AWS® in 293 patients with difficult airways. Anesthesiology 2009; 110:898–904. Malik MA et al. Randomized controlled trial of the Pentax AWS, Glidescope, and Macintosh laryngoscopes in predicted difficult intubation. Br J Anaesth 2009;103(5):761-8.
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Complications with GlideScope©
Incidence = 1% (N = 2004 intubations)
Minor
Lip, gum, dental trauma
Serious
Pharyngeal wall trauma, lingual nerve injury, vocal cord trauma, tonsillar perforation
Causes- blindly passing tube with stylet
Implication
Look down at airway and gently place tube until see on monitor
Appropriate size blade
Evaluate postop
Cooper RM. Complications associated with the use of the GlideScope videolaryngoscope. Can J Anaesth. 2007 ;54(1):54-7. Leong WL, Lim Y, Sia AT. Palatopharyngeal wall perforation during Glidescope intubation. Anaesth Intensive Care. 2008 ;36(6):870-4. Magboul MM, Joel S. The video laryngoscopes blind spots and possible lingual nerve injury by the Gliderite rigid stylet--case presentation and review of literature. Middle East J Anesthesiol. 2010;20(6):857-60.
Conclusion: Indirect Video Laryngoscopy Devices
All have major role in difficult airway management
Improved success in DI vs. direct laryngoscopy
Seeing vocal cords and placing tube 2 different things
Be careful with blindly placing tube
Limitations of devices Blood, vomit may obscure view Limited ROM, small TM distance and neck pathology/scar &
inexperience increase failure rate
Awake Fiberoptic Intubation How do you secure this
airway?
Awake vs. asleep
AFOB vs. Trach?
Could you ventilate this patient?
Do you know how to do an AFOB?
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Preparation for AFOB
Tip Concept
Explanation Pt understands reason
Desiccation Dry the airway
Dilation Prepare the nose
Topicalization Obtund reflexes
Sedation Maintain meaningful contact
Procrastination Don’t rush it!
Dr Rosenblatt’s tips
Preparation
Explain the procedure to them and reason why you are doing it
Desiccation Glycopyrolate 0.2-0.4 mg IV or IM if IV difficult Takes up to 15 minutes
Dilation Always prepare nose Afrin
Topicalization Nasal passage/nasopharynx Base of tongue/posterior oropharynx Hypopharynx/larynx-trachea
http://www.bing.com/images/search?q=images+of+fiberoptic+broncoschopy&qs=n&form=QBIR&pq=images+of+fiberoptic+broncoschopy&sc=0-21&sp=-1&sk=
Desiccation
http://www.bing.com/images/search?q=images+of+awake+fiberoptic+intubation&qs=n&form=QBIR&pq=images+of+awake+fiberoptic+intubation&sc=0-15&sp=-1&sk=
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Airway Innervation
http://www.bing.com/images/search?q=images+of+awake+fiberoptic+intubation&qs=n&form=QBIR&pq=images+of+awake+fiberoptic+intubation&sc=0-15&sp=-1&sk=
Nasal Topicalization
Anterior ethmoid nerve & nasopalantine nerve
Cotton swabs soaking with 4% lidocaine solution or 5% lidocaine ointment
Advance them slowly into the nasal passage
Incrementally advance
Keep in for 5 minutes
http://www.bing.com/images/search?q=images+of+awake+fiberoptic+intubation&qs=n&form=QBIR&pq=images+of+awake+fiberoptic+intubation&sc=0-15&sp=-1&sk=
Base of Tongue/Post Oropharynx
Glossopharyngeal nerve (IX)
Controls gag reflex
posterior third of the tongue
vallecula
anterior surface of the epiglottis
walls of the pharynx
tonsils
http://www.bing.com/images/search?q=images+of+awake+fiberoptic+intubation&qs=n&form=QBIR&pq=images+of+awake+fiberoptic+intubation&sc=0-15&sp=-1&sk=
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Base of Tongue/Post Oropharynx
Nebulizer
Good, but careful with lung uptake
Atomizer
Glossopharyngeal nerve
Blocks vs. cotton swabs
http://www.bing.com/images/search?q=images+of+awake+fiberoptic+intubation&qs=n&form=QBIR&pq=images+of+awake+fiberoptic+intubation&sc=0-15&sp=-1&sk=
Glossopharyngeal Nerve
Use forceps to slowly advance cotton soaked swabs to pillars and leave for 5 minutes each side
http://www.bing.com/images/search?q=images+of+awake+fiberoptic+intubation&qs=n&form=QBIR&pq=images+of+awake+fiberoptic+intubation&sc=0-15&sp=-1&sk=
SLN & RLN Superior laryngeal nerve
base of tongue posterior surface epiglottis aryepiglottic fold &
arytenoids
Recurrent laryngeal nerve Vocal cords and trachea
http://www.bing.com/images/search?q=images+of+awake+fiberoptic+intubation&qs=n&form=QBIR&pq=images+of+awake+fiberoptic+intubation&sc=0-15&sp=-1&sk=
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Hypopharynx/Trachea Blockade
Topical vs. blocks
Syringe w/ LA and angiocatheter
Hold tongue with gauze
Drip on base of the tongue
Drip until stop coughing
http://www.bing.com/images/search?q=images+of+awake+fiberoptic+intubation&qs=n&form=QBIR&pq=images+of+awake+fiberoptic+intubation&sc=0-15&sp=-1&sk=
Topicalization tips Drying agent VIP
Blocks used less and less
Test with tongue depressor or suction catheter
Make sure “numb enough” before going to OR
Sedation
Options Dexmedetomidine
0.5-1 mcg/bolus over 10 minutes
0.2-0.7 mcg/kg/hr
Titrate to effect
Midazolam
Fentanyl
Remifentanil 0.025-0.075 mcg/kg bolus
0.025-0.075 mcg/kg/min
VIP Maintain meaningful contact
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Williams & Ovassapian Airways
http://www.bing.com/images/search?q=images+of+awake+fiberoptic+intubation&qs=n&form=QBIR&pq=images+of+awake+fiberoptic+intubation&sc=0-15&sp=-1&sk=
FOB Conduits
http://www.bing.com/images/search?q=images+of+awake+fiberoptic+intubation&qs=n&form=QBIR&pq=images+of+awake+fiberoptic+intubation&sc=0-15&sp=-1&sk=
Tips for AFOB Take your time with topicalization and procedure
Soften tube in warm saline & use 0.5 to 1 size smaller ETT
Position-supine vs. semi-fowlers
Use Williams or Ovassapian airway
Jaw thrust to open airway
Add 10 mL syringe to side-port of FOB to inject LA on VCs
Rotate tube if meet resistance
Practice “asleep” FOB on healthy airways
Do AFOB whenever can to keep up skills
Other devices- some indirect devices can be used for awake intubation
Rosenstock CV et al. Awake fiberoptic or awake laryngoscopic tracheal intubation in patients with anticipated difficult airway management. Anesthesiology 2012; 116:1210–6
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Permission obtained from patient to videotape.
Extubation of Difficult Airway Can patient maintain patent airway after extubation?
Can the patient maintain adequate ventilation?
Is the patient fully reversed? Fully Awake?
Do you have a plan on how to reintubate?
Consider using airway exchange catheter
Airway Exchange Catheter
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Worst Case Scenario: Emergency Invasive Airway Access
http://emedicine.medscape.com/article/80241-overview#a15 http://www.bing.com/images/search?q=images+of+awake+fiberoptic+intubation&qs=n&form=QBIR&pq=images+of+awake+fiberoptic+intubation&sc=0-15&sp=-1&sk=
Difficult Airway Note
Schaeuble J C , Caldwell J E Anesth Analg 2009;109:684-686
Questions?
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References 1. Spence DL. Anesthesia Abstracts. 2010;4(12): 1-34.
2. Apfelbaum HL et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118.
3. Rosenblatt W H , Whipple J. The Difficult Airway Algorithm of the American Society of Anesthesiologists. Anesth Analg 2003;96:1233-1233.
4. Rosenblatt WH et al. Preoperative Endoscopic Airway Examination (PEAE) provides superior airway information and may reduce the use of unnecessary awake intubation. Anesth Analg 2011;112:602–7
5. Tremblay et al. Poor visualization during direct laryngoscopy and high upper lip bite test score are predictors of difficult intubation with the GlideScope® videolaryngoscope. Anesth Analg 2008;10(6): 1495–1500.
6. Díaz-Gómez JL, Satyapriya A, Satyapriya SV, et al. Standard clinical risk factors for difficult laryngoscopy are not independent predictors of intubation success with the GlideScope. J Clin Anesth. 2011;23(8):603-610.
References 7. Kheterpal S et al. Prediction and outcomes of impossible mask ventilation:
review of 50,000 anesthetics. Anesthesiology 2009;110:891-897. 8. Rao Sl et al. Laryngoscopy and tracheal intubation in the head-elevated
position in obese patients: a randomized, controlled, equivalence trial. Anesth Analg 2008;107:1912-1918.
9. Ikeda A et al. Effects of muscle relaxants on mask ventilation in anesthetized persons with normal upper airway anatomy. Anesthesiology 2012;117:487-93.
10. Amathieu R et al. An algorithm for difficult airway management, modified for modern optical devices (airtraq laryngoscope; ctrach™): a 2-year prospective validation in patients for elective abdominal, gynecological, and thyriod surgery. Anesthesiology 2011;114:25-33.
11. Nouruzi-Sedeh P et al. Laryngoscopy via Macintosh blade versus Glidescope: success and time for endotracheal intubation in untrained medical personnel. Anesthesiology 2009;110:32-7.
12. Aziz MF, Healy D, Kheterpal S, Fu RF, Dillman D, Brambrink AM. Routine clinical practice effectiveness of the Glidescope in difficult airway management: an analysis of 2,004 Glidescope intubations, complications, and failures from two institutions. Anesthesiology. 2011;114(1):34-41.
References 13. Greisdale DE et al. Glidescope® video-laryngoscopy versus direct
laryngoscopy for endotracheal intubation: a systematic review and meta-analysis. Can J Anesth. 2012; 59(1): 41–52.
14. Savoldelli GL et al. Comparison of the Glidescope, the McGrath, the Airtraq,and the Macintosh laryngoscopes in simulated difficult airways. Anaesthesia, 2008, 63, 1358–1364.
15. Asai T et al. Use of the Pentax-AWS® in 293 Patients with difficult airways. Anesthesiology 2009; 110:898–904.
16. Malik MA et al. Randomized controlled trial of the Pentax AWS, Glidescope, and Macintosh laryngoscopes in predicted difficult intubation. Br J Anaesth 2009 ;103(5):761-8.
17. Cooper RM. Complications associated with the use of the GlideScope videolaryngoscope. Can J Anaesth. 2007 Jan;54(1):54-7.
18. Leong WL, Lim Y, Sia AT. Palatopharyngeal wall perforation during Glidescope intubation. Anaesth Intensive Care. 2008 Nov;36(6):870-4.
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References 19. Magboul MM, Joel S. The video laryngoscopes blind spots and possible lingual nerve
injury by the Gliderite rigid stylet--case presentation and review of literature. Middle East J Anesthesiol. 2010;20(6):857-60.
20. Rosenstock CV et al. Awake fiberoptic or awake laryngoscopic tracheal intubation in patients with anticipated difficult airway management. Anesthesiology 2012; 116:1210–6
21. Moyers G, McDougle L. Use of the Cook airway exchange catheter in "bridging" the potentially difficult extubation: a case report. AANA J. 2002;70(4):275-278.
22. Schaeuble JC, Caldwell JE. Effective communication of difficult airway management to subsequent anesthesia providers. Anesth Analg. 2009;109(2):684-686.
23. Markowitz JE. Surgical airway access. Medscape. Retrieved from http://emedicine.medscape.com/article/80241-overview#a15 on Jan 21, 2013.
24. Taylor et al. The McGrath® Series 5 videolaryngoscope vs the Macintosh laryngoscope: a randomised, controlled trial in patients with a simulated difficult airway. Anaesthesia 2013;68: 142-47
25. Kheterpal S et al. Incidence, predictors, and outcome of difficult mask ventilation combined with difficult laryngoscopy. Anesthesiology 2013;119:1360-9