3. Airway management :
Comparative study between
McGrath VL and Airtraq OL
VS
Macintosh laryngoscope
in neutral neck position

4. Presented by
Alaa Elsayed Goma Falogy
M.Sc. of Anaesthesia and surgical intensive care
Faculty of medicine
Zagazig university
2016

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

6. Research question
If
used by [experienced anesthiologists] 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]?

7. Introductio
n

8. INTRODUCTION:
• 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.

9. Concept of line of sight
during direct laryngoscopy :

10. INTRODUCTION:
• 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) .
INTRODUCTION:

11. INTRODUCTION:
• These concerns have aroused the idea to develop
number of alternatives to classical Macintosh
laryngoscope such as Airtraq ® OL, 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

12. 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

13. NECK
EXTENSION

14. 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.

15. 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 .

16. Video Laryngoscopy in difficult
Airway management :

17. McGrath
Video-
Laryngoscope

18. 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

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

20. AIRTRAQ Optical Laryngoscope

21. AIRTRAQ Optical Laryngoscope
 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.

22. PATIENTS
AND
METHODS

23. 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 will receive standard monitoring
according to ASA guidelines.

24. 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.

25. CORMACK & LEHANE SCORE

26. 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.

27. McGrath VL;
INTUBATION TECHNIQUES
AND
SEQUENCE

28. 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.
 Now, move 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 video visualization, the ETT is then advanced on a
smooth curve through the glottis mediated by styllet.

29. Intubation sequence by McGrath VL

30. Intubation sequence by McGrath VL

31. Intubation sequence by McGrath VL

32. AIRTRAQ OL;
INTUBATION TECHNIQUES
AND
SEQUENCE

33. 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.

34. Intubation sequence by Airtraq OL
 Hold the device in the mouth in the midline by
right hand .
 advance by sliding the device over the tongue.
 check the image on view finder to optimize the
view by moving the blade as necessary by left
hand.
 Be sure that the laryngeal inlet is in the centre of
viewfinder just before pushing the ETT forward
by right hand .

35. Intubation sequence by Airtraq OL

36. Intubation sequence by Airtraq OL

37. Intubation sequence by Airtraq OL

38. RESULTS
OF
THE
STUDY

39. COMPARISON BETWEEN GROUPS
ARE DONE ACCORDING TO:
 INTUBATION CONDITIONS
 NUMBERS OF ATTEMPTS
 Optimization Procedures
 Cormack and Lehane score
 IDS
 SUCCESS RATE OF INTUBATION
 TIME TO INTUBATION
 HEMODYNAMICS
 COMPLICATIONS

40. 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)

41. DEMOGRAPHIC AND
AIRWAY ASSESSMENT DATA
Non-Significant

42. RESULTS OF THE STUDY
numbers of attempts
Macintosh group Airtraq group McGrath group
HS

43. RESULTS OF THE STUDY
Cormack-Lehane score in each group
43
Airtraq almost get C&L I
MacintoshleastinC&LI
Most views of McGrath C&L II
Macintosh most C&L II
HIGHLY-
SIGNIFICANT

44. RESULTS OF THE STUDY
IDS DISTRIBUTION
AirtraqendinIDS2
McGrathendsinIDS4
MacintoshendsinIDS7
HIGHLY-
SIGNIFICANT

45. RESULTS OF THE STUDY
SUCCESSFULNESS
45
Macintoshhas4failures
NON-
SIGNIFICANT

46. RESULTS OF THE STUDY
SUCCESSFULNESS
FAMILARITY
&
ADAPTATION

47. Post-hoc inter-group analysis
47
BETTER
IMAGE CONCEPT
THOERY
SAME
VIDEOSCOPE
EFFIENCY
FAMILARITYNO NEED FOR
ALIGNMENT

48. AIRTRAQ LEAST
MACINTOSH MOST

50. When it comes to intubation
time?
50
Again..Familiarity

51. RESULTS OF THE STUDY
Complications Occurrence
Sharp tip for
both devices
produce
more trauma
as primary
insult more
than
secondary
injury
Stylet
manipulation

52. LIMITATIONS
DESIGN
operator knows the devices, which may also introduce bias.
(solved by closed envelopes basis).
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.

53. SUMMARY
AND
CONCLUSION

54. The conclusion of this study proves
that Airtraq OL and McGrath VL
are: MORE EFFECTIVE AND SAFE
Than Macintosh Laryngoscope
in managing stimulated difficult
intubation situation in form of
cervical spine immobilization by
semi-rigid neck collar

55. RECOMMENDATIONS

56. This study recommends use of
videolaryngoscopes in our daily practice
specially in difficult airway scenarios such
as neck immobilization situations because
it provide better airway management even
without extensive training, and it is needed
to conduct similar studies upon real
cervical trauma patients for better
assessment of its advantages and
disadvantages.

57. 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

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

59. I would like to thank….
My family that suffered a
lot through all this period
of Ph.D. journey
And they deserve all love
and care

60. THANK YOU