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Introduction: There is uncertainty about the optimal videolaryngoscope for awake tracheal intubation in patients with anticipated difficult airway. The use of channelled and unchannelled videolaryngoscopy has been reported, but there is a lack of evidence on which is the best option., Methods: We conducted a randomised clinical trial to compare the efficacy of the C-MAC D-Blade® vs. Airtraq® in adult patients (aged ≥ 18 y) scheduled for elective or emergency surgery under general anaesthesia with anticipated difficult airway who required awake tracheal intubation under local anaesthesia and conscious sedation. The primary endpoint was the first-attempt tracheal intubation success rate. Secondary outcomes included the overall success rate; number of tracheal intubation attempts; Cormack and Lehane glottic view; level of difficulty (visual analogue score); patient discomfort (visual analogue score); and incidence of complications., Results: Ninety patients (70/90 male (78%); mean (SD) age 65 (12) y) with anticipated difficult airways were randomly allocated to C-MAC D-Blade or Airtraq videolaryngoscopy. First-attempt successful tracheal intubation rate was higher in patients allocated to the C-MAC D-Blade group compared with those allocated to the Airtraq group (38/45 (84%) vs. 28/45 (62%), respectively; p = 0.006). The proportion of patients' tracheas that were intubated at the second and third attempt was 4/45 (9%) and 3/45 (7%) in those allocated to the C-MAC D-Blade group compared with 14/45 (31%) and 1/45 (2%) in those allocated to the Airtraq group (p = 0.006). There was no significant difference in overall tracheal intubation success rate (C-MAC D-Blade group 45/45 (100%) vs. Airtraq group 43/45 (96%), p = 0.494)., Discussion: In patients with anticipated difficult airway, first-attempt awake tracheal intubation success rate was higher with the C-MAC D-Blade compared with Airtraq laryngoscopy. No difference was found between the two videolaryngoscopes in overall tracheal intubation success rate., (© 2024 Association of Anaesthetists.)

Background: Tracheal intubation in ICU is associated with high incidence of difficult intubations. The study aimed to investigate whether the "universal" use of a hyperangulated videolaryngoscope would increase the frequency of "easy intubation" in ICU patients compared to direct laryngoscopy., Methods: A prospective before-after study was conducted. The pre-interventional period (36 months) involved tracheal intubations using direct laryngoscopy as the first intubation option. In the interventional period (18 months) a hyperangulated videolaryngoscope was the first intubation option. The primary outcome was the percentage of patients with "easy intubation" defined as intubation on the first attempt and easy laryngoscopy (modified Cormack-Lehane glottic view of I-IIa). Secondary outcomes included difficult laryngoscopy, operator technical difficulty, and complications., Results: We enrolled 407 patients, 273 in non-interventional period, and 134 in interventional period. Tracheal intubation in the interventional period was associated with higher incidence of "easy intubation" (92.5%) compared with the non-interventional period (75.8%); P < 0.001)). Glottic visualization improved in the interventional period, with a reduced incidence of difficult laryngoscopy (1.5% vs. 22.5%; P < 0.001). The proportion of first-success rate intubation was 92.5% in the interventional period, and 87.8% in the non-interventional period (P = 0.147). Moderate and severe technical difficulty of intubation reported decreased in the interventional period (6% vs. 17.6%; P < 0.001). There was no significant difference between both periods in the incidence of complications., Conclusion: "Universal" use of hyperangulated videolaryngoscopy for tracheal intubation in patients admitted in ICU improves the percentage of easy intubation compared to direct laryngoscopy., (Copyright © 2024 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Aspiration of gastric contents is a recognised complication during all phases of anaesthesia. The risk of this event becomes more likely with repeated attempts at tracheal intubation. There is a lack of clinical data on the effectiveness of videolaryngoscopy relative to direct laryngoscopy rapid sequence intubation in the operating theatre. We hypothesised that the use of a videolaryngoscope during rapid sequence intubation would be associated with a higher first pass tracheal intubation success rate than conventional direct laryngoscopy. In this multicentre randomised controlled trial, 1000 adult patients requiring tracheal intubation for elective, urgent or emergency surgery were allocated randomly to airway management using a McGrath™ MAC videolaryngoscope (Medtronic, Minneapolis, MN, USA) or direct laryngoscopy. Both techniques used a Macintosh blade. First-pass tracheal intubation success was higher in patients allocated to the McGrath group (470/500, 94%) compared with those allocated to the direct laryngoscopy group (358/500, 71.6%), odds ratio (95%CI) 1.31 (1.23-1.39); p < 0.001. This advantage was observed in both trainees and consultants. Cormack and Lehane grade ≥ 3 view occurred less frequently in patients allocated to the McGrath group compared with those allocated to the direct laryngoscopy group (5/500, 1% vs. 94/500, 19%, respectively; p < 0.001). Tracheal intubation with a McGrath videolaryngoscope was associated with a lower rate of adverse events compared with direct laryngoscopy (13/500, 2.6% vs. 61/500, 12.2%, respectively; p < 0.001). These findings suggest that the McGrath videolaryngoscope is superior to a conventional direct laryngoscope for rapid sequence intubation in the operating theatre., (© 2024 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.)

While videolaryngoscopy has resulted in better overall success rates of tracheal intubation, airway assessment is still an important prerequisite for safe airway management. This study aimed to create an artificial intelligence model to identify difficult videolaryngoscopy using a neural network. Baseline characteristics, medical history, bedside examination and seven facial images were included as predictor variables. ResNet-18 was introduced to recognise images and extract features. Different machine learning algorithms were utilised to develop predictive models. A videolaryngoscopy view of Cormack-Lehane grade of 1 or 2 was classified as 'non-difficult', while grade 3 or 4 was classified as 'difficult'. A total of 5849 patients were included, of whom 5335 had non-difficult and 514 had difficult videolaryngoscopy. The facial model (only including facial images) using the Light Gradient Boosting Machine algorithm showed the highest area under the curve (95%CI) of 0.779 (0.733-0.825) with a sensitivity (95%CI) of 0.757 (0.650-0.845) and specificity (95%CI) of 0.721 (0.626-0.794) in the test set. Compared with bedside examination and multivariate scores (El-Ganzouri and Wilson), the facial model had significantly higher predictive performance (p < 0.001). Artificial intelligence-based facial analysis is a feasible technique for predicting difficulty during videolaryngoscopy, and the model developed using neural networks has higher predictive performance than traditional methods., (© 2023 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.)

Purpose: Nasotracheal intubation (NTI) is required for surgery in oropharyngeal (OP) carcinoma patients, but it may be challenging because of distorted anatomy, mucosal congestion, and increased risk of bleeding. Flexible bronchoscopy (FB)-guided NTI is preferred in these cases but has limitations. In this randomized controlled study, we sought to compare C-MAC ® D-BLADE-guided videolaryngoscopy (VL) (Karl Storz SE & Co. KG, Tuttlingen, Germany) with FB for NTI under general anesthesia in patients with OP carcinomas., Methods: We randomized a total of 100 patients with OP carcinoma and El-Ganzouri's risk index (EGRI) < 7 to undergo NTI under general anesthesia with FB (n = 50) or C-MAC D-BLADE-guided VL (n = 50). The primary outcome was the total intubation time. We also recorded the time to glottis view, nasal intubation difficulty scale (NIDS) score, best percentage of glottis opening score, and complications., Results: The median [interquartile range (IQR)] total intubation time was shorter with VL than with FB (total intubation time, 38 [26-43] sec vs 60 [52-65] sec; difference, -20 sec [95% confidence interval (CI), -27 to -11]; P < 0.001). Similarly, the median [IQR] time to glottis view was shorter with VL compared to FB (8 [6-9] sec vs 22 [14-25] sec; difference, -13 sec [95% CI, -17 to -10]; P < 0.001). The median NIDS score was higher with VL (difference, 2 [95% CI, 2 to 3]; P < 0.001). The incidences of airway trauma (two cases with FB vs seven with VL; P = 0.30) and postoperative sore throat (ten cases in both groups; P = 0.56) were similar., Conclusion: Compared to FB, C-MAC D-BLADE-based VL reduced the total time for nasal intubation oropharyngeal carcinoma patients, potentially representing an acceptable alternative in selected cases., Trial Registration: CTRI.nic.in (2018/11/0162830); first submitted 8 November 2018., (© 2024. Canadian Anesthesiologists' Society.)

Background: Transesophageal echocardiogram probe insertion in intubated critically ill patients can be difficult, leading to complications, such as gastric bleeding or lesions in the oropharyngeal mucosa. We hypothesised that the use of a videolaryngoscope would facilitate the first attempt at insertion of the transesophageal echocardiogram probe and would decrease the incidence of complications compared to the conventional insertion technique., Methods: In this clinical trial, patients were randomly assigned the insertion of a transesophageal echocardiogram probe using a videolaryngoscope or conventional technique. The primary outcome was the successful transesophageal echocardiogram probe insertion on the first attempt. The secondary outcomes included total success rate, number of insertion attempts, and incidence of pharyngeal complications., Results: A total of 100 intubated critically ill patients were enrolled. The success rate of transesophageal echocardiogram probe insertion on the first attempt was higher in the videolaryngoscope group than in the conventional group (90% vs. 58%; absolute difference, 32%; 95% CI 16%-48%; p < 0.001). The overall success rate was higher in the videolaryngoscope group than in the conventional group (100% vs. 72%; absolute difference, 28%; 95% CI 16%-40%; p < 0.001). The incidence of pharyngeal mucosal injury was smaller in the videolaryngoscope group than in the conventional group (14% vs. 52%; absolute difference, 38%; 95% CI 21%-55%; p < 0.001)., Conclusions: Our study showed that in intubated critically ill patients required transesophageal echocardiogram, the use of videolaryngoscope resulted in higher successful insertion on the first attempt with lower rate of complications when compared with the conventional insertion technique., Trial Registration: ClinicalTrials.gov Identifier: NCT04980976., (Copyright © 2024 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Difficult airway management represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report with updated recommendations for the management of difficult airway in adults. These recommendations were developed based on the consensus of a group of expert anesthesiologists, aiming to provide strategies for managing difficulties during tracheal intubation. They are based on evidence published in international guidelines and opinions of experts. The report underlines the essential steps for proper difficult airway management, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and maintaining arterial oxygenation. Additional strategies for using advanced tools, such as video laryngoscopy, flexible bronchoscopy, and supraglottic devices, are discussed. The report considers recent advances in understanding crisis management, and the implementation seeks to further patient safety and improve clinical outcomes. The recommendations are outlined to be uncomplicated and easy to implement. The report underscores the importance of ongoing education, training in realistic simulations, and familiarity with the latest technologies available., Competing Interests: Conflicts of interest The authors declare no conflicts of interest., (Copyright © 2023 Sociedade Brasileira de Anestesiologia. Published by Elsevier España S.L.U. All rights reserved.)

Children with difficult tracheal intubation are at increased risk of severe complications, including hypoxaemia and cardiac arrest. Increasing experience with the simultaneous use of videolaryngoscopy and flexible bronchoscopy (hybrid) in adults led us to hypothesise that this hybrid technique could be used safely and effectively in children under general anaesthesia. We reviewed observational data from the international Pediatric Difficult Intubation Registry from 2017 to 2021 to assess the safety and efficacy of hybrid tracheal intubation approaches in paediatric patients. In total, 140 patients who underwent 180 attempts at tracheal intubation with the hybrid technique were propensity score-matched 4:1 with 560 patients who underwent 800 attempts with a flexible bronchoscope. In the hybrid group, first attempt success was 70% (98/140) compared with 63% (352/560) in the flexible bronchoscope group (odds ratio (95%CI) 1.4 (0.9-2.1), p = 0.1). Eventual success rates in the matched groups were 90% (126/140) for hybrid vs. 89% (499/560) for flexible bronchoscope (1.1 (0.6-2.1), p = 0.8). Complication rates were similar in both groups (15% (28 complications in 182 attempts) hybrid; 13% (102 complications in 800 attempts) flexible bronchoscope, p = 0.3). The hybrid technique was more likely than flexible bronchoscopy to be used as a rescue technique following the failure of another technique (39% (55/140) vs. 25% (138/560), 2.1 (1.4-3.2) p < 0.001). While technically challenging, the hybrid technique has success rates similar to other advanced airway techniques, few complications and may be considered an alternative technique when developing an airway plan for paediatric patients whose tracheas are difficult to intubate under general anaesthesia., (© 2023 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.)

Background: Tracheal intubation is a high-risk procedure in the critically ill, with increased intubation failure rates and a high risk of other adverse events. Videolaryngoscopy might improve intubation outcomes in this population, but evidence remains conflicting, and its impact on adverse event rates is debated., Methods: This is a subanalysis of a large international prospective cohort of critically ill patients (INTUBE Study) performed from 1 October 2018 to 31 July 2019 and involving 197 sites from 29 countries across five continents. Our primary aim was to determine the first-pass intubation success rates of videolaryngoscopy. Secondary aims were characterising (a) videolaryngoscopy use in the critically ill patient population and (b) the incidence of severe adverse effects compared with direct laryngoscopy., Results: Of 2916 patients, videolaryngoscopy was used in 500 patients (17.2%) and direct laryngoscopy in 2416 (82.8%). First-pass intubation success was higher with videolaryngoscopy compared with direct laryngoscopy (84% vs 79%, P=0.02). Patients undergoing videolaryngoscopy had a higher frequency of difficult airway predictors (60% vs 40%, P<0.001). In adjusted analyses, videolaryngoscopy increased the probability of first-pass intubation success, with an OR of 1.40 (95% confidence interval [CI] 1.05-1.87). Videolaryngoscopy was not significantly associated with risk of major adverse events (odds ratio 1.24, 95% CI 0.95-1.62) or cardiovascular events (odds ratio 0.78, 95% CI 0.60-1.02)., Conclusions: In critically ill patients, videolaryngoscopy was associated with higher first-pass intubation success rates, despite being used in a population at higher risk of difficult airway management. Videolaryngoscopy was not associated with overall risk of major adverse events., Clinical Trial Registration: NCT03616054., (Copyright © 2023 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Videolaryngoscopy is a suitable alternative to flexible bronchoscopy to facilitate awake tracheal intubation. The relative effectiveness of these techniques in clinical practice is unknown. We compared flexible nasal bronchoscopy with Airtraq ® videolaryngoscopy in patients with an anticipated difficult airway scheduled for awake tracheal intubation. Patients were allocated randomly to flexible nasal bronchoscopy or videolaryngoscopy. All procedures were performed with upper airway regional anaesthesia blockade and a target-controlled intravenous infusion of remifentanil. The success rate with the allocated technique was the primary outcome. A non-inferiority analysis with a predefined limit of 8% was planned. Seventy-eight patients were recruited, allocated randomly and analysed. The rate of successful intubation was 97% and 82% in the flexible bronchoscopy and videolaryngoscopy groups, respectively, p = 0.032. The median (IQR [range]) time to tracheal intubation was shorter with the Airtraq, 163 (105-332 [40-1004]) vs. 217 (180-364 [120-780]) s, p = 0.030. There were no significant differences for complications found between the groups. The median visual analogue scale for ease of intubation was 8 (7-9 [0-10]) for Airtraq vs. 8 (7-9 [0-10]) for flexible bronchoscopy, p = 0.710. The median visual analogue scale for patient comfort for Airtraq was 8 (6-9 [2-10]) vs. 8 (7-9 [3-10]) for flexible bronchoscopy, p = 0.370. The Airtraq videolaryngoscope is not non-inferior to flexible bronchoscopy for awake tracheal intubation in a clinical setting when awake tracheal intubation is indicted. It may be a suitable alternative when judged on a case-by-case basis., (© 2023 Association of Anaesthetists.)

Background: Respiratory therapists (RTs) have historically performed safe and effective intubations, yet there are limited multi-center data assessing their intubation performance. Multi-center data can be used to compare RT intubation performance to that of other professions and identify quality improvement opportunities at hospitals where RTs perform intubation. We aimed to explore the feasibility of a multi-center collaborative to evaluate RT intubation outcomes., Methods: A data collection tool was developed by the authors and implemented at two institutions. Following institutional review board approval at each center and completion of data-use sharing agreements, data were collected between May 25, 2020-April 30, 2022, and combined for analysis. Descriptive statistics were used to compare overall success rate, first-attempt success rate, adverse events (AEs), and type of laryngoscopy., Results: There were a total of 689 intubation courses where RTs made an attempt, 363 from center A and 326 from center B. Center A captured 85% of all RT intubation courses, and center B captured 63%. Overall, RTs were successful in 98% of attempts. RTs made 86% of initial attempts. The most common indications for intubation were cardiac arrest (42%) and respiratory failure (31%). Videolaryngoscopy was used during 65% of initial attempts and was associated with higher first-attempt success rate, higher overall success rate, and fewer AEs. Airway-related adverse event rate was 8.7%; physiologic AE rate was 16%, and desaturation rate was 11%., Conclusions: A collaborative examining RTs intubation performance was successfully initiated at 2 separate facilities. Intubations performed by RTs had a high success rate, with AE rates comparable to published results from other types of providers., Competing Interests: Mr Miller discloses relationships with Saxe Communications and S2N Health. Mr Miller is a section editor for Respiratory Care. Mr Emberger discloses relationships with Dräger Medical and Avanos. Dr Rotta discloses relationships with Breas United States, Vapotherm, and Elsevier. Mr Gillin has disclosed no conflicts of interest., (Copyright © 2023 by Daedalus Enterprises.)

Purpose: In adult mannequins, videolaryngoscopy improves glottic visualization with lower force applied to upper airway tissues and reduced task workload compared with direct laryngoscopy. This trial compared oropharyngeal applied forces and subjective workload during direct vs indirect (video) laryngoscopy in a neonatal mannequin., Methods: We conducted a randomized crossover trial of intubation with direct laryngoscopy, straight blade videolaryngoscopy, and hyperangulated videolaryngoscopy in a neonatal mannequin. Thirty neonatal/pediatric/anesthesiology consultants and residents participated. The primary outcome measure was the maximum peak force applied during intubation. Secondary outcome measures included the average peak force applied during intubation, time needed to intubate, and subjective workload., Results: Direct laryngoscopy median forces on the epiglottis were 8.2 N maximum peak and 6.8 N average peak. Straight blade videolaryngoscopy median forces were 4.7 N maximum peak and 3.6 N average peak. Hyperangulated videolaryngoscopy median forces were 2.8 N maximum peak and 2.1 N average peak. The differences were significant between direct laryngoscopy and straight blade videolaryngoscopy, and between direct laryngoscopy and hyperangulated videolaryngoscopy. Significant differences were also found in the top 10th percentile forces on the epiglottis and palate, but not in the median forces on the palate. Time to intubation and subjective workload were comparable with videolaryngoscopy vs direct laryngoscopy., Conclusions: The lower force applied during videolaryngoscopy in a neonatal mannequin model suggests a possible benefit in reducing potential patient harm during intubation, but the clinical implications require assessment in future studies., Registration: ClinicalTrials.gov (NCT05197868); registered 20 January 2022., (© 2023. Canadian Anesthesiologists' Society.)

Background: Using a Macintosh-style videolaryngoscope as a first-intention device for tracheal intubation of unselected patients in the operating room has not often been studied. We hypothesised that using a Macintosh-style videolaryngoscope as a first-intention device is associated with an increased proportion of easy tracheal intubation., Methods: In a quality improvement project for airway management aimed at implementing a Macintosh-style videolaryngoscope as a first-intention device, we included all consecutive tracheal intubations in adults from March, 2017 to September, 2020 in two French teaching hospitals. We divided the cohort into three temporal cohorts: the pre-intervention, implementation, and post-intervention periods. The primary outcome was the proportion of easy airway management. The secondary outcomes were the rescue technique, Cormack-Lehane III or IV view, and operator-reported difficulty of intubation. Data from one hospital compliant with the quality improvement project were compared with data from a non-compliant hospital., Results: A total of 26 692 tracheal intubations were performed. Among 11 938 intubations included in the compliant hospital, 5487 were included in the pre-intervention, 1845 in the implementation, and 4606 in the post-intervention periods. In comparison to the pre-intervention period, the proportions of easy tracheal intubation increased from 94.3% (5177 of 5487) to 98.7% (4547 of 4606)) in the post-intervention period (+4.4% [95% confidence interval 3.7-5.1%], P<0.001). In comparison to the pre-intervention period, all secondary outcome proportions were significantly lower in the post-intervention period. No significant changes were noted in the non-compliant hospital between the pre- and post-intervention periods., Conclusions: Using a Macintosh-style videolaryngoscope as a first-intention device for tracheal intubation in the operating room was associated with a significant increase in the proportion of easy tracheal intubation, compared with use of the standard Macintosh laryngoscope., (Copyright © 2022 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: Tracheal intubation is a commonly performed procedure that can be associated with complications and result in patient harm. Videolaryngoscopy (VL) may decrease this risk as compared with Macintosh direct laryngoscopy (DL). This review evaluates the risk and benefit profile of VL compared with DL in adults., Methods: We searched MEDLINE, Embase, CENTRAL, and Web of Science on February 27, 2021. We included RCTs comparing VL with DL in patients undergoing tracheal intubation in any setting. We separately compared outcomes according to VL design: Macintosh-style, hyperangulated, and channelled., Results: A total of 222 RCTs (with 26 149 participants) were included. Most studies had unclear risk of bias in at least one domain, and all were at high risk of performance and detection bias. We found that videolaryngoscopes of any design likely reduce rates of failed intubation (Macintosh-style: risk ratio [RR]=0.41; 95% confidence interval [CI], 0.26-0.65; hyperangulated: RR=0.51; 95% CI, 0.34-0.76; channelled: RR=0.43, 95% CI, 0.30-0.61; moderate-certainty evidence) with increased rates of successful intubation on first attempt and better glottic views across patient groups and settings. Hyperangulated designs are likely favourable in terms of reducing the rate of oesophageal intubation, and result in improved rates of successful intubation in individuals presenting with difficult airway features (P=0.03). We also present other patient-oriented outcomes., Conclusions: In this systematic review and meta-analysis of trials of adults undergoing tracheal intubation, VL was associated with fewer failed attempts and complications such as hypoxaemia, whereas glottic views were improved., Systematic Review Registration: This article is based on a Cochrane Review published in the Cochrane Database of Systematic Reviews (CDSR) 2022, Issue 4, DOI: 10.1002/14651858.CD011136.pub3 (see www.cochranelibrary.com for information). Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and the CDSR should be consulted for the most recent version of the review., (Copyright © 2022 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Objectives: To assess a new application of artificial intelligence for real-time detection of laryngeal squamous cell carcinoma (LSCC) in both white light (WL) and narrow-band imaging (NBI) videolaryngoscopies based on the You-Only-Look-Once (YOLO) deep learning convolutional neural network (CNN)., Study Design: Experimental study with retrospective data., Methods: Recorded videos of LSCC were retrospectively collected from in-office transnasal videoendoscopies and intraoperative rigid endoscopies. LSCC videoframes were extracted for training, validation, and testing of various YOLO models. Different techniques were used to enhance the image analysis: contrast limited adaptive histogram equalization, data augmentation techniques, and test time augmentation (TTA). The best-performing model was used to assess the automatic detection of LSCC in six videolaryngoscopies., Results: Two hundred and nineteen patients were retrospectively enrolled. A total of 624 LSCC videoframes were extracted. The YOLO models were trained after random distribution of images into a training set (82.6%), validation set (8.2%), and testing set (9.2%). Among the various models, the ensemble algorithm (YOLOv5s with YOLOv5m-TTA) achieved the best LSCC detection results, with performance metrics in par with the results reported by other state-of-the-art detection models: 0.66 Precision (positive predicted value), 0.62 Recall (sensitivity), and 0.63 mean Average Precision at 0.5 intersection over union. Tests on the six videolaryngoscopies demonstrated an average computation time per videoframe of 0.026 seconds. Three demonstration videos are provided., Conclusion: This study identified a suitable CNN model for LSCC detection in WL and NBI videolaryngoscopies. Detection performances are highly promising. The limited complexity and quick computational times for LSCC detection make this model ideal for real-time processing., Level of Evidence: 3 Laryngoscope, 132:1798-1806, 2022., (© 2021 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To quantify dental forces during double-lumen tube intubations with different laryngoscopy techniques., Design: Experimental biomechanical mannequin study., Setting: Two German university hospitals., Participants: One hundred four anesthesiologists with varying levels of experience., Interventions: Participants performed a sequence of intubations on a mannequin equipped with hidden forces sensors in the maxillary incisors. Different laryngoscopy techniques were evaluated under normal and difficult airway conditions. Direct laryngoscopy was compared with different videolaryngoscopy techniques: the C-MAC with a Macintosh blade, the GlideScope, and the KingVision with hyperangulated blades., Measurements and Main Results: A total of 624 intubations were evaluated. In normal airway conditions, the median (interquartile range [range]) peak forces were significantly lower when the GlideScope (15.7 (11.3-22.0 [2.1-110.5]) N) was used compared with direct laryngoscopy (21.0 (14.1-28.5[4.7-168.6]) N) (p = 0.007). In difficult airways, resulting forces were reduced using hyperangulated videolaryngoscopes (GlideScope: -13.7 N [p < 0.001]; KingVision: -11.9 N [p < 0.001]) compared with direct laryngoscopy, respectively. The time to intubation was prolonged with the use of the KingVision (25.5 (17.1-41.9[9.2-275.0])s [p < 0.001]) in comparison to direct laryngoscopy (20.8 (15.9-27.4[8.7-198.6]) s). The C-MAC demonstrated the shortest time to intubation., Conclusions: Although hyperangulated videolaryngoscopes improve dental strain, clinicians also should consider the time to intubation, which is shortest with nonhyperangulated videoblades, when choosing a laryngoscopy technique on an individual patient basis., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Tracheal intubation is the gold standard in emergency airway management. One way of measuring intubation quality is first pass success rate (FPSR). Mastery of tracheal intubation and maintenance of the skill is challenging for non-anesthesiologists. A combination of individual measures can increase FPSR. Videolaryngoscopy is an important tool augmenting laryngeal visualization. Bougie-first strategy can further improve FPSR in difficult airways. Standardized positioning maneuvers and manipulation of the soft tissues can enhance laryngeal visualization. Fresh frozen cadavers (FFC) are superior models compared to commercially manufactured manikins. By purposefully manipulating FFCs, it is possible to mimic the pre-hospital intubation conditions of helicopter emergency medical service (HEMS)., Methods: Twenty-four trauma surgeons (12 per Group, NOVICES: no pre-hospital experience, HEMS: HEMS physicians) completed an airway training course using FFCs. The FFCs were modified to match airway characteristics of 60 prospectively documented intubations by HEMS physicians prior to the study (BASELINE). In four scenarios the local HEMS airway standard (1: unaided direct laryngoscopy (DL), OLD) was compared to two scenarios with modifications of the intubation technique (2: augmented DL (bougie and patient positioning), 3: augmented videolaryngoscopy (aVL)) and a control scenario (4: VL and bougie, positioning by participant, CONTROL). FPSR, POGO score, Cormack and Lehane grade and duration of intubation were recorded. No participant had anesthesiological qualifications or experience in VL., Results: The comparison between CONTROL and BASELINE revealed a significant increase of FPSR and achieved C&L grade for HEMS group (FPSR 100%, absolute difference 23%, p ≤ .001). The use of videolaryngoscopy, bougie, and the application of positioning techniques required significantly more time in the CONTROL scenario (HEMS group: mean 34.0 s (IQR 28.3-47.5), absolute difference to BASELINE: 13.0 s, p = .045). The groups differed significantly in the median number of real-life intubations performed in any setting (NOVICES n = 5 (IQR 0-18.75), HEMS n = 68 (IQR 37.25-99.75)). In the control scenario no significant differences were found between both groups. The airway characteristics of the FFC showed no significant differences compared to BASELINE., Conclusion: Airway characteristics of a pre-hospital patient reference group cared for by HEMS were successfully reproduced in a fresh frozen cadaver model. In this setting, a combination of evidence based airway management techniques results in high FPSR and POGO rates of non-anesthesiological trained users. Comparable results (FPSR, POGO, duration of intubation) were achieved regardless of previous provider experience. The BOAH concept can therefore be used in the early stages of airway training and for skill maintenance., (© 2022. The Author(s).)

Background: Tracheal intubation in patients with coronavirus disease-19 is a high-risk procedure that should be performed with personal protective equipment (PPE). The influence of PPE on operator's performance during tracheal intubation remains unclear., Methods: We conducted a systematic review and meta-analysis of simulation studies to evaluate the influence of wearing PPE as compared to standard uniform regarding time-to-intubation (TTI) and success rate. Subgroup analyses were conducted according to device used and operator's experience., Results: The TTI was prolonged when wearing PPE (eight studies): Standard Mean Difference (SMD) -0.54, 95% Confidence Interval [-0.75, -0.34], p <  0.0001. Subgroup analyses according to device used showed similar findings (direct laryngoscopy, SMD -0.63 [-0.88, -0.38], p < 0.0001; videolaryngoscopy, SMD -0.39 [-0.75, -0.02], p =  0.04). Considering the operator's experience, non-anesthesiologists had prolonged TTI (SMD -0.75 [-0.98, -0.52], p < 0.0001) while the analysis on anesthesiologists did not show significant differences (SMD -0.25 [-0.51, 0.01], p = 0.06). The success rate of tracheal intubation was not influenced by PPE: Risk Ratio (RR) 1.02 [1.00, 1.04]; p = 0.12). Subgroup analyses according to device demonstrated similar results (direct laryngoscopy, RR 1.03 [0.99, 1.07], p = 0.15, videolaryngoscopy, RR 1.01 [0.98, 1.04], p =  0.52). Wearing PPE had a trend towards negative influence on success rate in non-anesthesiologists (RR 1.05 [1.00, 1.10], p = 0.05), but not in anesthesiologists (RR 1.00 [0.98, 1.03], p = 0.84). Trial-sequential analyses for TTI and success rate indicated robustness of both results., Conclusions: Under simulated conditions, wearing PPE delays the TTI as compared to dressing standard uniform, with no influence on the success rate. However, certainty of evidence is very low. Performing tracheal intubation with direct laryngoscopy seems influenced to a greater extent as compared to videolaryngoscopy. Similarly, wearing PPE affects more the non-anesthesiologists subgroup as compared to anesthesiologists., (Copyright © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.)

Purpose: This study aims to analyse differences in fiberoptic laryngoscopy (FOL) versus high definition laryngoscopy (HDL) by examining videolaryngoscopy images by a large group of observers with different levels of clinical expertise in ear, nose and throat (ENT) medicine., Methods: This study is a 111 observer paired analysis of laryngoscopy videos during an interactive presentation. During a National Meeting of the Dutch Society of ENT/Head and Neck Surgery, observers assessed both FOL and HDL videos of nine cases with additional clinical information. Observers included 41 ENT consultants (36.9%), 34 ENT residents (30.6%), 22 researchers with Head and Neck interest (19.8%) and 14 with unspecified clinical expertise (12.6%). For both laryngoscopic techniques, sensitivity, specificity, positive and negative predictive value and diagnostic accuracy were determined for identifying a normal glottis, hyperkeratosis, radiotherapy adverse effects and squamous cell carcinoma. The sensitivities for FOL and HDL were analysed with regard to the different levels of clinical expertise., Results: The overall sensitivity for correctly identifying the specific histological entity was higher in HDL (FOL 61% vs HDL 66.3%, p < 0.05). HDL was superior to FOL in identifying a normal glottis (FOL 68.1% vs HDL 91.6%, p < 0.01) and squamous cell carcinoma (FOL 70.86% vs HDL 79.41%, p = 0.02). Residents and researchers with Head and Neck interest diagnosed laryngeal lesions more correctly with HDL (p < 0.05)., Conclusions: In a large population of observers with different levels of clinical expertise, HDL is superior to FOL in identifying laryngeal lesions.

Objective: Development of transnasal fiberoptic laryngoscopy, integration of an operative channel (OC), the advent of high-definition television imaging, with improvements in laser technology, cleared the way for office-based laryngology. Three treatment categories can be identified: bioendoscopy-guided biopsy; laryngeal injection; laser-assisted surgery., Methods: 26 patients underwent OBPs at the Otolaryngology Clinic of IRCCS Policlinico San Martino, Genoa, Italy. Sixty-eight procedures were performed: 60 for recurrent respiratory papillomatosis (RRP), 5 for unilateral vocal fold paralysis (UVFP) and 3 for glottic leukoplakias. Neoblucaine 5% was administrated through the operative channel, for local anaesthesia. All procedures were carried out with the physician standing behind the patient. Narrow band imaging (NBI - Olympus Medical) or i-scan (Pentax Medical) were used to enhance the accuracy of the biopsy thanks to identification of atypical vascular patterns. Laryngeal injections were made using a 25G flexible needle. Opera Evo (Quanta system IEC/EN 60825-1:2007) is a hybrid fibre laser that is used for "blanching" and vaporisation of RRP lesions and to treat selected leukoplakias that were previously biopsied., Conclusions: No major complications occurred during the procedures., (Copyright © 2021 Società Italiana di Otorinolaringoiatria e Chirurgia Cervico-Facciale, Rome, Italy.)

Purpose: In the preceding 20 years, many randomized-controlled trials and meta-analyses have compared direct Macintosh laryngoscopy with videolaryngoscopy. The videolaryngoscope blades have included both traditional Macintosh blades and hyperangulated blades. Macintosh and hyperangulated blades differ in their geometry and technique for tracheal intubation; certain patient populations may benefit from one blade type over another. The primary objective of this systematic review was to assess whether published meta-analyses comparing direct Macintosh laryngoscopy to videolaryngoscopy have accounted for the videolaryngoscope blade type. Secondary objectives evaluated heterogeneity among practitioner experience and specialty, clinical context, patient population, and original primary study outcomes., Source: A search was performed across Ovid Medline, Ovid Embase, ClinicalKey, PubMed, TRIP, AccessAnesthesiology, Google Scholar, and ANZCA discovery. A systematic review identified meta-analyses which compared direct Macintosh laryngoscopy to videolaryngoscopy. There were no patient age or clinical specialty restrictions. Exclusion criteria included non-English language, studies comparing non-Macintosh blade to videolaryngoscopy, and studies in awake patients., Principal Findings: Twenty-one meta-analyses were identified that were published between 1 January 2000 and 7 May 2020. Macintosh and hyperangulated videolaryngoscope blades were combined in most studies (16/21; 76%). Heterogeneity was also present among practitioner experience (20/21; 95%), clinician specialty (15/21; 71%), and clinical locations (10/21; 48%). Adult and pediatric patients were combined or not defined in 5/21 studies (24%). The primary outcomes of the meta-analyses varied, with the most common (7/21; 33%) being first-pass tracheal intubation success., Conclusions: Heterogeneity across important clinical variables is common in meta-analyses comparing direct Macintosh laryngoscopy to videolaryngoscopy. To better inform patient care, future videolaryngoscopy research should differentiate blade type, clinical context, and patient-related primary outcomes.

Introduction: Endotracheal intubation may be required for the transport of critically ill neonates and children. Data suggest that first pass success (FPS) is associated with lower rates of complications. Thus, understanding factors associated with FPS can have important implications for clinical outcomes. We aimed to determine the impact of videolaryngoscopy (VL) on FPS by a pediatric critical care transport team (CCTT). Methods: We performed a retrospective cross-sectional study on pediatric patients (≤ 18 years of age) requiring endotracheal intubation by a tertiary care-based pediatric CCTT between 2011 and 2019. Patients were categorized as neonatal (≤ 28 days of age, either preterm or term) or pediatric (> 28 days of age). All intubation attempts using VL were performed with the C-MAC videolaryngoscope. Our primary outcome was rate of FPS. Descriptive statistics of patient, provider, and procedure characteristics were calculated. Multivariate regression was used to test the association between FPS and type of laryngoscope (video versus direct) adjusting for significant clinical predictors. Results: Over the study period, 135 patients were intubated by the CCTT. Sixty percent of these patients were neonates, and 40% were pediatric. The overall FPS rate was 61%, with lower rates in neonates (54%) and higher rates in pediatric patients (70%). Use of videolaryngoscopy increased over the study period. First pass success rate using the C-MAC videolaryngoscope was 72% compared to 42% for direct laryngoscopy across the whole study population. In adjusted analyses, FPS using VL was significantly higher in the pediatric patient population (aOR 12.42 [95%CI 3.33, 46.29]), but not in neonates (aOR 1.08 [0.44, 2.63]). Use of VL increased significantly over the study period. Conclusion: We found use of a C-MAC videolaryngoscope by a critical care transport team was associated with improved FPS during endotracheal intubation of pediatric patients but not neonates, after controlling for other patient and provider characteristics. In addition to the impact on FPS, use of VL may offer additional educational and quality benefits.

Objective: Anatomical and physiological differences in paediatric and adult airways make intubation of paediatric patients a challenge. This study aimed to compare the efficacy and safety of video laryngoscopy (VL) to direct laryngoscopy (DL) on intubation outcomes in paediatric patients., Design: Systematic review and meta-analysis., Setting: Operating room., Patients: Paediatric patients who needed tracheal intubation., Intervention: Video laryngoscopy or direct laryngoscopy., Measurements: Electronic searches in PubMed, Embase, and the Cochrane Library were performed to identify relevant randomized controlled trials published through January 2020. Outcomes included time to intubate, intubation failure at first attempt, Cormack-Lehane laryngeal view grade, intubation difficulty scale (IDS), percentage of glottic opening score (POGO), optimal external laryngeal manipulation (OLEM), and complications. Relative risks and weighted mean difference (WMD), with 95% CI, were employed to calculate summary results using a random-effects model., Main Results: Overall, 27 trials including 2461 paediatric patients were analysed. Children with video laryngoscopy intubation required longer time to intubate than direct laryngoscopy intubation (WMD 3.41, 95% CI: 1.29-5.53, P = 0.002), whereas infants receiving video laryngoscopy and direct laryngoscopy intubation experienced similar time to intubate (WMD 1.72, 95% CI: -1.09-4.54, P = 0.230). No significant differences were observed on intubation failure at first attempt between video laryngoscopy and direct laryngoscopy intubations in children and infants, respectively. Video laryngoscopy improved the POGO and intubation trauma but not Cormack-Lehane laryngeal view grade, IDS, external laryngeal manipulation, hoarseness, or oxygen desaturation., Conclusions: Compared with direct laryngoscopy intubation, there were no benefits for paediatric patients with video laryngoscopy on time to intubate and failure at first attempt, but there were benefits with regard to POGO and intubation trauma., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Transesophageal echocardiography (TEE) is a well-established procedure, but serious complications may occur. This systematic review and meta-analysis assessed the utility of videolaryngoscopy-assisted technique in TEE probe insertion. We performed a systematic search in MEDLINE, EMBASE, CENTRAL, and ICTRP. We included RCTs comparing TEE probe insertion techniques assisted with videolaryngoscopy and with any other insertion technique in adult patients. Primary outcome measures were (1) the number of attempts before successful TEE probe insertion, and (2) the risk of any procedural injury to related structures. The secondary outcome measure was time to TEE probe insertion. In total, three studies (n = 266) were included in this systematic review. Overall, a significantly less number of attempts were required with videolaryngoscopy-assisted insertion (mean difference [MD] - 0.60; 95% confidence interval [CI] - 0.73, - 0.46; low quality of evidence). Videolaryngoscopy-assisted technique was also associated with smaller risk of complications (risk ratio [RR] 0.17; 95% CI 0.05, 0.62; low quality of evidence). There was no significant difference in time to probe insertion (MD - 8.57; 95% CI - 26.31, 9.16; very low quality of evidence). The use of videolaryngoscopy for TEE probe insertion is associated with a significant reduction in the number of attempts and complication rate.

Neonatal intubation is an essential but difficult skill to learn. Videolaryngoscopy allows the airway view to be shared by the intubator and supervisor and improves intubation success. Ideally, a videolaryngoscope (VL) should be usable as a conventional laryngoscope (CL). The aims of this report were to describe differences in the shape of currently available CL and VL blades and to compare the direct airway view obtainable on a neonatal manikin with different laryngoscope blades.Three main differences were observed; compared with CL, the VL blades have a reduced vertical height, a curved tip and curved body. The direct airway view obtained by the VL is narrower than that obtained with the CL, although the corresponding view on the VL screen is maintained.Minor adaptation of intubation technique may be required when using a VL. Modifying VL blades to reduce these differences may improve their usefulness as an intubation training tool., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

With different videolaryngoscopes for pediatric patients available, UEScope can be used in all age groups. The aim of this study was to compare the Miller laryngoscope and UEScope in pediatric intubation by paramedics in different scenarios. Overall, 93 paramedics with no experience in pediatric intubation or videolaryngoscopy performed endotracheal intubation in scenarios: (A) normal airway without chest compressions, (B) difficult airway without chest compressions, (C) normal airway with uninterrupted chest compressions, (D) difficult airway with uninterrupted chest compressions. Scenario A. Total intubation success with both laryngoscopes: 100%. First-attempt success: 100% for UEScope, 96.8% for Miller. Median intubation time for UEScope: 13 s [IQR, 12.5-17], statistically significantly lower than for Miller: 14 s [IQR, 12-19.5] (p = 0.044). Scenario B. Total efficacy: 81.7% for Miller, 100% for UEScope (p = 0.012). First-attempt success: 48.4% for Miller, 87.1% for UEScope (p = 0.001). Median intubation time: 27 s [IQR, 21-33] with Miller, 15 s [IQR, 14-21] with UEScope (p = 0.001). Scenario C. Total efficiency: 91.4% with Miller, 100% with UEScope (p = 0.018); first-attempt success: 67.7 vs. 90.3% (p = 0.003), respectively. Intubation time: 21 s [IQR, 18-28] for Miller, 15 s [IQR, 12-19.5] for UEScope. Scenario D. Total efficiency: 65.6% with Miller, 98.9% with UEScope (p < 0.001); first-attempt success: 29.1 vs. 72% (p = 0.001), respectively. Intubation time: 38 s [IQR, 23-46] for Miller, 21 s [IQR, 17-25.5] for UEScope.Conclusion: In pediatric normal airway without chest compressions, UEScope is comparable with Miller. In difficult pediatric airways without chest compressions, UEScope offers better first-attempt success, shorted median intubation time, and improved glottic visualization. With uninterrupted chest compressions in normal or difficult airway, UEScope provides a higher first-attempt success, a shorter median intubation time, and a better glottic visualization than Miller laryngoscope. What is Known: • Endotracheal intubation is the gold standard for adult and children airway management. • More than two direct laryngoscopy attempts in children with difficult airways are associated with a high failure rate and increased incidence of severe complications. What is New: • In difficult pediatric airways with or without chest compressions, UEScope in inexperienced providers in simulated settings provides better first-attempt efficiency, median intubation time, and glottic visualization.

Our hypothesis was that intubations with the McGRATH MAC videolaryngoscope in elderly patients would produce less hemodynamic responses and ECG changes than the Macintosh direct laryngoscope. The patients were divided into two groups: patients who were intubated using the McGRATH MAC (Group V, n = 45) and patients who were intubated using the Macintosh direct laryngoscope (Group L, n = 45). Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial blood pressure (MAP), heart rate (HR) were recorded before induction with anesthesia (baseline), immediately after induction and at 1 min, 3 min, and 5 min after intubation, with simultaneous ECG. When Group L was compared to Group V, there was an increase in the first, third and fitth minutes after intubation in terms of HR. SBP, MAP increased only at 1 min after intubation and DBP increased in the first and third minutes after intubation in Group L. In Group L, there was a significant difference in the HR values immediately after induction and the first minute after intubation compared with the baseline values. There was a difference in the SBP values immediately after induction and at 3 min and 5 min after intubation compared with the baseline values. There was a difference in DBP and MAP values immediately after induction and at 5 min after intubation. When the McGRATH MAC videolaryngoscope was compared with the Macintosh direct laryngoscope in elderly patients, the McGRATH MAC videolaryngoscope decreased the hemodynamic fluctuations due to tracheal intubation., (© 2019 The Authors. Kaohsiung Journal of Medical Sciences published by John Wiley & Sons Australia on behalf of Kaohsiung Medical University.)

Although videolaryngoscopy plays a major role in the 2015 Difficult Airway Society guidelines, the impact on anaesthetic assistant working practices and training has not previously been reported. We surveyed anaesthetic assistants in our hospital to document their experience with using the C-MAC © videolaryngoscope (48 practitioners, 100% response rate). Improvements in the following were reported: patient safety 100%; ability to see whether laryngoscopy is difficult 98%; ability to anticipate the 'next step' 98%; team-working and human factors 96%; ability to call a senior anaesthetist more quickly 94%; assessment or adjustment of cricoid force application 92%, understanding of laryngeal anatomy 92%; training in intubation 98%; training in cricoid force application 87%. Concerns were primarily about local issues such as decontamination and blade availability. Ninety percent reported that the clinical benefit outweighed any additional workload. In conclusion, the C-MAC © videolaryngoscope is judged by anaesthetic assistants to confer numerous advantages for their working practice and training.

Emergency airway management in children is generally considered to be challenging, and endotracheal intubation requires a high level of personal skills and experience. Immobilization of the cervical spine is indicated in all patients with the risk of any cervical spine injury but significantly aggravates endotracheal intubation. The best airway device in this setting has not been established yet, although the use of videolaryngoscopes is generally promising. Seventy-five moderately experienced paramedics of the Emergency Medical Service of Poland performed endotracheal intubations in a pediatric manikin in three airway scenarios: (A) normal airway, (B) manual in-line cervical immobilization, and (C) cervical immobilization using a Patriot cervical extrication collar and using two airway techniques: (1) McGrath videolaryngoscope and (2) Macintosh blade in a randomized sequence. First-attempt intubation success rate, time to intubation, glottis visualization, and subjective ease of intubation were investigated in this study. Intubation of difficult airways, including manual in-line and cervical collar immobilization, using the McGrath was significantly faster, with a higher first-attempt intubation success rate, better glottic visualization, and ease of intubation, compared to Macintosh-guided intubation. In the normal airway, both airway techniques performed equal., Conclusion: Our manikin study indicates that the McGrath may be a reasonable first intubation technique option for endotracheal intubation in difficult pediatric emergencies. Further clinical studies are therefore indicated. What is known : • Airway management in pediatrics is challenging and requires a high level of skills and experience. Cervical immobilization is indicated in all patients with any risk of cervical spine injury, but it significantly aggravates endotracheal intubation in these patients. Videolaryngoscopes have been reported to ease intubation and provide better airway visualization in the regular clinical setting. What is new: • The McGrath is an easy-to-use and clinically often used videolaryngoscope, but it has never been investigated in pediatrics with an immobilized cervical spine. In the normal airway, the McGrath provided better airway visualization compared to Macintosh laryngoscopy. However, better visualization did not lead to decreased time to intubation and a higher success rate of the first intubation attempt. In difficult airways, the McGrath provided better airway visualization and this led to faster intubation, a higher first-attempt intubation success rate, and better ease of intubation compared to Macintosh-guided intubation.

D-blade is a relatively new device in the field of videolaryngoscopy, designed for airway management by enabling indirectoscopic glottic view. In our study, we investigated efficiency of D-blade in comparison with direct Macintosh laryngoscope (gold standard). Fifty-two adult patients with normal airway scheduled for elective surgery in general anesthesia were randomly assigned in D-blade video or direct Macintosh group. In the first video group, patients were laryngo-scoped and intubated by D-blade, and in the second group laryngoscopy and intubation were performed by Macintosh laryngoscope. Glottic view was evaluated according to Cormack Lehane grading system (C-L), while duration of intubation and easiness of intubation were evaluated according to the intubation difficulty score (IDS). Additionally, hemodynamic parameters were recorded before and after induction. There were no statistically significant between-group differences in time to intubation, easiness of endotracheal tube insertion, C-L, and IDS. In comparison with direct Macintosh laryngoscope, D-blade showed similar but still favorable characteristics. In our opinion, D-blade is a useful device in airway management and should be used in daily anesthesiologist work.

In addition to being effective and easy to learn how to use, the ideal laryngoscope should be associated with minimal reduction in skill performance during gaps in practice over time. We compared the time taken to intubate the trachea of a manikin by novice medical students immediately after training, and then after 1 month, with no intervening practice. We designed a two-period, four-group, randomised, cross-over trial to compare the Macintosh, Venner(™) A.P. Advance(™) with difficult airway blade, C-MAC(®) with D-Blade and Airtraq(®) with wireless video-viewer. A bougie was used to aid intubation with the Macintosh and the C-MAC. After training, there was no significant difference in median (IQR [range]) intubation time using the videolaryngoscopes compared with the Macintosh, which took 30 (26.5-35 [12-118])s. One month later, the intubation time was longer using the C-MAC (41 (29.5-52 [20-119])s; p = 0.002) and A.P. Advance (40 (28.5-57.5 [21-107])s; p = 0.0003)m compared with the Macintosh (27 (21-29 [16-90])s); there was no difference using the Airtraq (27 (20.5-32.5 [15-94])s; p = 0.258) compared with the Macintosh. While skill acquisition after a brief period of learning and practice was equal for each laryngoscope, performance levels differed after 1 month without practice. In particular, the consistency of performance using the C-MAC and A.P. Advance was worse compared with the Macintosh and the Airtraq. While the clinical significance of this is doubtful, we believe that reliable and consistent performance at laryngoscopy is desirable; for the devices that we tested, this requires regular practice., (© 2016 The Association of Anaesthetists of Great Britain and Ireland.)

We compared awake fibreoptic intubation with awake intubation using the Pentax Airway Scope(®) in 40 adult patients. Sedation was achieved using a target-controlled remifentanil infusion of 1-5 ng.ml(-1) and midazolam. The airway was anaesthetised with lidocaine spray and gargle. The total procedure time - a composite of sedation time, topical anaesthesia time and intubation time - was recorded. The operator's impression of the ease of the procedure and the patients' reported comfort were recorded on a 0-100 mm visual analogue scale. The median (IQR [range]) for total procedure time was 900 (739-1059 [616-1215]) s with the fibrescope and 651 (601-720 [498-900]) s with the Pentax Airway Scope (p = 0.0001). The median (IQR [range]) intubation time was 420 (283-480 [120-608]) s with the fibrescope and 183 (144-220 [107-420]) s with the Pentax Airway Scope (p = 0.0002). The median (IQR [range]) visual analogue scores for the operator's ease of intubation for the fibrescope and Pentax Airway Scope were 83.6 (72.0-98.0 [49.0-100.0]) and 86.8 (84.0-91.0 [61.0-100.0]), respectively (p = 0.3507). The median (IQR [range]) visual analogue score for patient comfort was 85.5 (81.0-97.0 [69.0-100.0]) and 79.4 (74.0-85.0 [59.0-100.0]) for the fibrescope and Pentax Airway Scope, respectively (p = 0.06). Total procedure time was significantly shorter with the Pentax Airway Scope compared with the fibrescope, with no difference in procedure difficulty or patient discomfort., (© 2016 The Association of Anaesthetists of Great Britain and Ireland.)