|Year : 2019 | Volume
| Issue : 4 | Page : 340-344
Effect of cuff inflation technique in video laryngoscopic assisted nasal intubation in oral cancer surgeries
Kinna G Shah, Bhavna C Shah, Mehul Patel
Department of Anaesthesia, B J Medical College, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
|Date of Submission||12-Sep-2018|
|Date of Acceptance||17-Dec-2018|
|Date of Web Publication||8-Jul-2019|
Kinna G Shah
Model House, Shastri Park, Nehru Nagar Cross Roads, Ambawadi, Ahmedabad - 380 016, Gujarat
Source of Support: None, Conflict of Interest: None
Introduction: TA scope is an indirect optical video laryngoscope (VL) which provides a better glottic view without manipulating all three airway axis. Cuff inflation in nasal tube (NT) makes tube midline and good alignment with glottic opening. Aim: This study aims to evaluate the success rate of nasal intubation with cuff inflation technique through VL. Methods: A total of 50 patients posted for oral cancer surgery were included. After general anesthesia induction, NT passed up to oropharynx; with VL NT cuff inflation with 15 ml of air done in Group I and no cuff inflation in Group D. NT was advanced to vocal cords, cuff was deflated; the NT was then advanced into the trachea, and then cuff was reinflated (M0). If this failed, cuff inflation was further inflated 5 cc more (M1) or counterclockwise 180° rotation (M3) or help of Magill's forceps (M3) was used. Results: NT tip locations were midline in 88% after cuff inflation. The duration of intubation was earlier in inflated group (32 ± 18 s vs. 44 ± 20 s). Additional maneuvers such as more 5 cc air or Magill forceps were more in Group D (52% vs. 22% P = 0.25). First trail intubation success without any maneuvers was 48% in Group I and 12% Group D (P = 0.006). Counterclockwise 180° endotracheal tube rotation (M2) was useful to pass NT to VC in 32%, 48% Group I and D, respectively (P = 0.25). Air required for cuff inflation was 16.57 ± 2.65 ml in Group I. Conclusion: Cuff inflation technique has a good success rate with minimum additional assistance in video laryngoscopic nasal intubation.
Keywords: Cuff inflation, nasal intubation, videolaryngoscopy
|How to cite this article:|
Shah KG, Shah BC, Patel M. Effect of cuff inflation technique in video laryngoscopic assisted nasal intubation in oral cancer surgeries. Med J DY Patil Vidyapeeth 2019;12:340-4
|How to cite this URL:|
Shah KG, Shah BC, Patel M. Effect of cuff inflation technique in video laryngoscopic assisted nasal intubation in oral cancer surgeries. Med J DY Patil Vidyapeeth [serial online] 2019 [cited 2020 Mar 29];12:340-4. Available from: http://www.mjdrdypv.org/text.asp?2019/12/4/340/262230
| Introduction|| |
Nasotracheal intubation (NTI) is must for oncological surgical procedures involving oral cavity or laryngeal structures.
During video laryngoscopic-assisted nasal intubations, difficulties arise in the visualization of nasal tube (NT) in oropharynx or manipulation with Magill forceps. Hence, cuff inflation technique which was previously described for blind nasal intubation was used by us in this study.
The TA scope is a newer video laryngoscope (VL) [Figure 1] that available with a slim and thin blade; it has been used successfully for orotracheal and NTI. This study was conducted to assess the intubating conditions using the anesthetist VL (TA scope) (manufactured and marketed by Divya enterprise, Rajkot, Gujarat, India). This is the first-ever study for nasal intubation in oral cancer and its reconstructive surgeries, using newer, self-designed VL by the private practicing anesthetist.
When endotracheal (ET) cuff is being inflated with 15 ml of air, its lifts up ETT from the posterior pharyngeal wall and make it easier to see in VL monitor and perfect alignment toward the glottis. Once tip of ETT is passed to glottic opening, cuff is deflated, and tube is pushed gently into trachea through vocal cords to achieve intubation and cuff is re-inflated.
Our aim of the study was to evaluate the effectiveness of cuff inflation technique using VL (TA scope) for NTI during NTT.
| Materials and Methods|| |
After Local Ethics Committee approval (letter number IRC/2018/P-78, dated 24 August 2018) and written informed consent, we recruited 60 patients of 20–65 years of age, the American Society of Anesthesiology (ASA) Grade I and II having mouth opening of least 1.5 cm posted for elective oncological oral surgery requiring nasal intubation. Patients of obvious difficult intubation (having MPG Grade III and IV) and carcinoma of vocal cords were excluded from the study.
All patients were randomly divided into two groups, 25 patients in each group by chit method. Group I: NTT Cuff inflation technique with VL and Group D: NTT Cuff deflated technique with VL.
The topical preparation of the nasal cavity by instilling xylometazoline 0.05% two drops into each nostril, 5 min before the induction of anesthesia and 2 puffs of 10% lidocaine spray was done in both nostrils in both groups. Standard monitors (pulse oximeter, noninvasive blood pressure cuff, capnography, and electrocardiography [ECG]) were attached.
Intravenous (IV) access was established, and slow infusion of crystalloids commenced. Patients were premedicated with injection glycopyrrolate 0.004 mg/kg, injection fentanyl citrate 2 μg/kg were administered IV slowly in all the two groups. Patients were preoxygenated with 6 L/min for 3 min.
All patients received injection lidocaine 1.5 mg/kg IV, and anesthesia was induced with, injection thiopentone sodium 5 mg/kg IV. A bolus dose of the injection succinylcholine 2 mg/kg IV was given after loss of eyelash reflex. Thereafter, a 7.0 no polyvinyl chloride ET cuffed for female and 8 no ETT for male was inserted through predetermined nostril until its tip lies in the pharynx (approximately 18–20 cm from the nostril).
Next, VL (the anesthetist scope-TA scope, Divya enterprise, Rajkot) was passed into the patient's mouth over the tongue in the midline. After the distal end of the VL was positioned with the glottis in the center of the monitor, laryngeal opening (C-L grading) was obtained. The patients were then intubated as per group allocation.
In cuff inflation Group I, the cuff was inflated with 15 ml of air by an assistant, and the ET tube (ETT) brought into view of the TA scope monitor screen. NT was pushed to align it with laryngeal inlet. After tube on vocal cord, the cuff was deflated, and tube was pushed down further into trachea. In group D, intubation was done with simply pushing ET tube and cuff deflated. Cuff was re inflated after ET tube is in trachea. Then with the help of Magill forceps, ETT was guided toward laryngeal inlet and intubation done.
The correct placement of ETT was confirmed by auscultation and capnograph tracing.
Heart rate (HR), mean arterial pressure (MAP), and SpO2 were measured at baseline T0, at the time of induction, T1, and at 2 min T2 and at 5 min T5, after 10 min T10 thereafter.
Any complications such as upper airway and oral injuries, hypoxia, and ETT cuff damage due to instrumentation were recorded.
If a decrease in saturation to 90% or lower was observed during nasal intubation, then oral intubation was performed. (1) Our own departmental fiberoptic bronchoscope was out of order at that time. (2) This is our departmental protocol for securing airway first by oral route first as bleeding is the major problem in failure to intubate in oral cancer cases. We postponed the surgery on that day, planned it next time with other department's fiberoptic scope intubation planned.
After ET intubation, the subsequent anesthetic management was continued as per the need. The sequence of intubation maneuvers in Group I was as follows. MO ETT passed by simple push, M1 counterclockwise 90° rotation, M2 counterclockwise 180° rotation, M3 cuff inflated with additional 5 cc air, M4 use of Magill's forceps, M5 use of external manipulation, and M6 - M4 + M3.
The following parameters were noted during the study Cormack Lehane grading for laryngeal view, time required for intubation, need for maneuvers for intubation (intubation without any maneuver M0, need for the maneuvers, and type of maneuver used: M0–M6), hemodynamic changes, lowest recorded SpO2 during intubation attempt and occurrence of any other complications.
The duration of NTI was defined as the time taken from the insertion of the VLscope through incisor till the passage of ETT through vocal cords by visual confirmation by the intubating anesthesiologist. The duration of NTI more than 120 s, fall in SpO2 below 90% during the procedure were considered as failed NTI.
All data were compared using unpaired t-tests. Statistical analysis was performed using WWW.graphpad.com. The percentage calculation was done by Medcalc software online mention about the sample size calculation. If sample size calculation was not done please mention that it was a pilot study. Yes, this study should called a pilot study, as this video laryngoscope was newly added device in our department and this was done in small study group.
| Results|| |
All patients of both groups were comparable to each other in age, sex, and weight. NTT was successful in all patients in both groups. Twelve (48%) patients in Group I intubated at first attempt without any manipulations. In 15 (60%) patients, ETT tip located posterior positions and seven were at lateral tip positions before cuff inflation. By inflating ET cuff with 15-20 ml in these cases, the nasotracheal tube tip was aligned satisfactorily toward the glottis, and NTI was successfully completed. The air volume required for cuff inflation was 16.57 ± 2.65 mL with a range from 15 to 20 ml.
We found no significant difference in airway assessment using C-L grading in both groups [Table 1].
|Table 1: Intubation time, complicationdata add a table on demographics as well|
Click here to view
The ETT with the cuff inflated easily aligned the glottis but advancing the tube into the trachea after the cuff Deflated, manipulation needed in 13 (52%) cases in group I, though intubation was successful in all patients [Table 2].
Cardiovascular parameters show significant difference except at baseline [Table 3]. After induction, mean blood pressure (MBP) decreased in both groups when compared to preinduction values. Patients in Group D show a significant rise in HR and blood pressure whereas in Group I [Table 4] and [Table 5]. HR and MBP were significantly stable in Group I (intragroup analysis table). Oxygen saturation as measured by pulse oximeter (SpO2) was maintained at 94% in all patients. No patients complained of sore throat in the postoperative period.
| Discussion|| |
In recent years, video laryngoscopy has become routine option for ET intubations in anesthesia practice. Direct laryngoscopy with the Macintosh blade and use of Magill's forceps to direct ETT into glottic opening, is time-consuming and may lead to trauma to surrounding structures and damage ETT cuff.
Our results have shown that NTI with cuff inflation with 15 ml of air with the help of the TA scope provided a higher rate of first trail success for NTI in patients who underwent oral cancer surgeries by avoiding Magill's forceps.
Cuff inflation technique for NTI was first explained by Gorback MS in late eighties  and was first demonstrated by van Elstraete et al. in early nineties. This technique of cuff inflation has been described for blind nasal intubation in spontaneously breathing patients. However, the technique was found to be less useful for successful intubation in their study.
The VL s are providing visualization of the vocal cords without the need to align the oropharyngeal and tracheal axes. The cuff inflation has also been described for BNI and laryngoscope-guided NTI  Glidescope VL, C Mac VL.
VLs may provide a better glottic view than the Macintosh laryngoscope in patients with head and neck cancers., Compare to other VL, this TA scope assembly, having thinner blade requires only 1.5 cm of mouth opening; still, it gives the advantage of getting better Cormack-Lehane grading. The TA scope (the anesthetist scope) device is affordable and portable with a two-piece design. The reusable monitor [Figure 2] is attached to a reusable blade with a specially incorporated channel for the bougie. This device has been described in orally intubated patients with bougie. The advantage of the TA-scope is its shape which allows for easier and less traumatic intubation and helped the supporting staff to assist intubation.
Videolaryngoscopy provides a good glottic view with lesser force as compared to direct laryngoscopy to the base of the tongue. Therefore, video laryngoscopy is less likely to stimulate pressure response and induce local tissue injury.
Direct laryngoscopy, laryngoscope blade elevates tongue and moves the larynx upward. Hence, even with Magill's forceps tube passed easily in trachea. While in video laryngoscopy, no need to insert the blade deep in the mouth or required force to lift up anterior wall of the neck. Hence, there are difficulties experienced to insert the ETT in trachea and 90° or 180° anti clock direction maneuvers required in many cases in our study. Walls et al. described a patient where extreme difficulty in using the glide scope occurred despite a CL Grade 1 laryngoscopic view because “the trachea formed a steep posterior angle with the laryngeal/glottic axis” with the ETT tip consequently becoming stuck against the anterior tracheal wall. Successful intubation was ultimately achieved by rotating the ETT 180°, thereby redirecting the ETT posteriorly.
Patients in Group D required a longer time to intubate (44 ± 20 s) than to Group I (32 ± 18 s) because more additional maneuvers (M2, 3, 4) was required. Patil VV  observed the same for positive correlation between the maneuvers used and the intubation time required in both groups. Time to intubation is less with cuff inflation technique.
Cuff inflation technique reduced stress response Swapnil  and airway injuries by avoiding the use of Magill forceps., It can increase the success rate of difficult NTI. In our study, cuff inflation technique helps in many ways like it avoids the need of Magill forceps, avoids instrumental trauma to upper airway mucosa, avoids ETT cuff damage and decreases intubation time. Hence, it contributes to minimize intubation stress response in Group I.
In addition, NTI through the left nostril required more manipulations than right side nostril used. Similar findings have been reported earlier by Baddoo and Phillips  why we cannot find or prove the reason behind more success through left nostril, we cannot find any other citation or Baddoo et al. also not mentioned also. It is our observation in daily practice in nasal intubation also.
We had maintained neutral neck position in our study during intubations. The success of NTI was significantly not affected with a position of the head with intubation with cuff inflation technique.,,
Out of 50 patients, patients had soreness or irritation of the throat was present in 40.38% Deshmukh et al., 9% in VL group jones, compared to the direct laryngoscopy group 34%. We had observed sore throat 12%; however, we extubated the all patients after 15–17 h of surgeries.
VL s are helpful learning aid to the newly joined residents for intubation as this device does not require much skill and is easier to use than conventional direct laryngoscopy. In our setup, this device was used for the first time and gives amazing feeling that paramedic staff has seen laryngeal structure for the first time.
| Conclusion|| |
Cuff inflation is a simple and successful way to assist NTI using TA scope. This technique TA scope reduced stress response and airway injuries due to Magill forceps and makes an easier and successful NTI intubation.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Patil VV, Subramanya BH, Kiranchand N, Bhaskar SB, Dammur S. Does C-MAC® video laryngoscope improve the nasotracheal intubating conditions compared to Macintosh direct laryngoscope in paediatric patients posted for tonsillectomy surgeries? Indian J Anaesth 2016;60:732-6.
] [Full text]
Gorback MS. Inflation of the endotracheal tube cuff as an aid to blind nasal endotracheal intubation. Anesth Analg 1987;66:916-7.
van Elstraete AC, Pennant JH, Gajraj NM, Victory RA. Tracheal tube cuff inflation as an aid to blind nasotracheal intubation. Br J Anaesth 1993;70:691-3.
Chung YT, Sun MS, Wu HS. Blind nasotracheal intubation is facilitated by neutral head position and endotracheal tube cuff inflation in spontaneously breathing patients. Can J Anaesth 2003;50:511-3.
Gupta N, Garg R, Saini S, Kumar V. GlideScope video laryngoscope-assisted nasotracheal intubation by cuff-inflation technique in head and neck cancer patients. Br J Anaesth 2016;116:559-60.
Jones PM, Armstrong KP, Armstrong PM, Cherry RA, Harle CC, Hoogstra J, et al.
A comparison of glidescope videolaryngoscopy to direct laryngoscopy for nasotracheal intubation. Anesth Analg 2008;107:144-8.
Hazarika H, Saxena A, Meshram P, Kumar Bhargava A. A randomized controlled trial comparing C mac D blade and macintosh laryngoscope for nasotracheal intubation in patients undergoing surgeries for head and neck cancer. Saudi J Anaesth 2018;12:35-41.
Walls RM, Samuels-Kalow M, Perkins A. A new maneuver for endotracheal tube insertion during difficult glideScope intubation. J Emerg Med 2010;39:86-8.
Malik MA, Subramaniam R, Maharaj CH, Harte BH, Laffey JG. Randomized controlled trial of the pentax AWS, glidescope, and macintosh laryngoscopes in predicted difficult intubation. Br J Anaesth 2009;103:761-8.
Khadake SM, Swamy G, Deshmukh A, Gujar S, More GS, Ratheesh GK. Cuff inflation technique under king vision video laryngoscope superior to conventional method of Magill forceps for nasotracheal intubation. Sch J App Med Sci 2016;4:1226-30.
Kaki AM, Almarakbi WA, Fawzi HM, Boker AM. Use of airtraq, C-mac, and glidescope laryngoscope is better than Macintosh in novice medical students' hands: A manikin study. Saudi J Anaesth 2011;5:376-81.
Hirabayashi Y, Seo N. Nasotracheal intubation using the airtraq versus Macintosh laryngoscope: A manikin study. Anesth Prog 2008;55:78-81.
Baddoo HK, Phillips BJ. Cuff inflation to aid nasotracheal intubation using the C-MAC videolaryngoscope. Ghana Med J 2011;45:84-6.
Deshmukh SR, Gadkari CP, Badwaik GM, Bhure AR. Effect of endotracheal tube cuff inflation and head position on the success of blind nasotracheal intubation. Int J Cur Res Rev 2014;6:24-30.
Magill IW. Blind nasal intubation. Anaesthesia 1975;30:476-9.
Murphy LD, Kovacs GJ, Reardon PM, Law JA. Comparison of the king vision video laryngoscope with the macintosh laryngoscope. J Emerg Med 2014;47:239-46.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]