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Department of Anesthesiology, Sapporo Medical University, School of Medicine, Chuo-ku, Sapporo, Japan
Address correspondence and reprint requests to Kohki Nishikawa, MD, Department of Anesthesiology, Sapporo Medical University School of Medicine, S-1, W-16, Chuo-ku, Sapporo, 060-0061, Japan.
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Abstract |
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P) in each variable was calculated. In normotensive patients, significantly larger P in systolic blood pressure was observed in the LN group than in the TN group (P < 0.05). In hypertensive patients, there were no significant differences between the LH group and the TH group in P after intubation. The time-to-intubation and number of attempts in the lightwand groups were significantly longer and more frequent than those in the laryngoscope groups (P < 0.05). The number of patients who complained of hoarseness was larger in the lightwand groups than in the laryngoscope groups (P < 0.05). We conclude that the lightwand technique significantly attenuates hemodynamic changes after intubation in comparison with the laryngoscopic technique in normotensive patients. However, in hypertensive patients, there is no difference in hemodynamic changes between the two techniques. Implications: A lightwand technique was accompanied by less hemodynamic changes after tracheal intubation than the laryngoscopic technique in normotensive patients. In hypertensive patients, however, no difference was found between the two techniques.
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Introduction |
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An advanced lightwand technique (6,7), in contrast to the laryngoscope, is expected to attenuate hemodynamic changes after tracheal intubation in normotensive patients because of the absence of stimulation (8). It would be desirable if the lightwand technique could attenuate precipitous hemodynamic changes in hypertensive patients. We tested the hypothesis that the lightwand (Trachlight [TL]; Laerdal Medical Inc., Sapporo, Japan) device-assisted intubation attenuates hemodynamic changes after tracheal intubation in comparison with the Macintosh laryngoscopic intubation in hypertensive patients.
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Methods |
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Patients were premedicated with atropine, 0.01 mg/kg, and midazolam, 0.05 mg/kg IM 30 min before the induction of anesthesia. Standard monitors were used (BSM-8300; Nihonkohden, Sapporo, Japan). Anesthesia was induced with IV 2 g/kg fentanyl, followed by 2 mg/kg propofol 3 min later. Vecuronium, 0.15 mg/kg, was given after loss of consciousness. The lungs were ventilated via mask with 100% oxygen until the trachea was intubated orally by using either the lightwand (TN and TH groups) or the Macintosh laryngoscope (LN and LH groups) 2 min after the administration of vecuronium.
In the TN and TH groups, the lightwand was introduced into the endotracheal tube, and the proximal end of the tube was bent to a 90° angle. Room lights were dimmed while the endotracheal tube was introduced into the oral cavity and advanced until midline illumination was observed in the anterior neck. Then, the stylet was withdrawn and the endotracheal tube was advanced until the glow disappeared behind the sternum. After the removal of the lightwand, the position of the endotracheal tube was confirmed by auscultation.
Three attempts at intubation were allowed for both techniques. Failure of intubation was defined as the inability to intubate after three attempts. An alternative technique was introduced in cases of failure. The duration of each attempt, namely the time from the introduction of the device into the oral cavity until its removal was recorded. The duration of intubation was defined as the sum of the duration of all intubation attempts with each technique. The hemodynamic changes after tracheal intubation were evaluated after successful tracheal intubation.
Blood pressure and heart rate were recorded at the following times: a) before the administration of fentanyl (baseline and an average of 3 independent determinations), b) 2 min after the administration of vecuronium (before intubation), c) immediately after tracheal intubation, and d) 1, 2, 3, 4, and 5 min after tracheal intubation. All intubations were performed by a single investigator experienced in using the lightwand and laryngoscope.
At the conclusion of surgery and anesthesia, extubation was performed by using routine extubation criteria. After extubation, all patients were asked about sore throat and hoarseness.
Data were presented as mean (SD). Statistical comparisons were performed by analysis of variance, followed by Student’s t-test. Pearson’s correlation coefficient was used to determine the relationship between the increase from baseline values and total time-to-intubation. Spearman’s rank correlation was used to determine the relationship between the increase from baseline values and all intubation attempts. A P = 0.05 was considered statistically significant.
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Results |
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P) in SBP were observed in the LN group compared with the TN group (P < 0.05) (Figure 2).
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P in SBP. Values of P in SBP and DBP were significantly greater in the LH and TH groups than in the LN and TN groups, respectively (P < 0.01) (Figure 2).
There were no significant correlations between the increases in SBP, DBP, or HR from the baseline to "immediately after intubation" and the number of attempts in normotensive and hypertensive groups. However, significant correlation was found between P and the number of attempts in the hypertensive groups (P = 0.047).
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Discussion |
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Orotracheal intubation by using a laryngoscope requires elevation of the epiglottis and exposure of the glottis, obtained by forward and upward lifting of the laryngoscope blade. These procedures are associated with hemodynamic changes (1–3). Although a transient hemodynamic change is of little consequence to healthy people, it may be hazardous to hypertensive patients because of their more labile cardiovascular system (4,5).
Our results showing that the lightwand technique caused smaller hemodynamic changes in normotensive patients than the laryngoscopic was not consistent with a previous report (9), which revealed no difference between the devices. Moreover, this report (9) suggested that in the lightwand technique, the grasping of the jaw and lifting it upward by using the thumb and index finger to make a clear passage for the tracheal tube had been sufficient to cause hemodynamic change. However, this observation is unlikely to be relevant to our study because this procedure was not used. The lightwand technique does not require the mouth to be wide open, the epiglottis to be elevated, or brought forward and lifted upward by a laryngoscope. Although it is not obvious how much laryngoscopy-induced stimulation directly contributes to hemodynamic changes after endotracheal intubation, a lack of direct stimuli to the mouth and the larynx would be one of the main explanations for the small hemodynamic changes in normotensive patients being intubated by the lightwand technique.
In hypertensive patients, in contrast to our expectation, the lightwand technique failed to attenuate increases in arterial blood pressure after intubation. The hemodynamic response of hypertensive and normotensive patients is different. Goldman and Caldera (10) reported that hypertension was accompanied with three to four times more hypertensive episodes than in normotensive patients because of long-term persistent vascular hyperreactivity. Although the lightwand technique was less invasive than the laryngoscopic technique in normotensive patients, it is not completely free of stimulation. Endotracheal intubation by lightwand is a light-guided technique without visualization of the laryngeal structures. Thus, if the tip of the lightwand does not enter the trachea directly, an intense stimuli is applied to the upper airway (11), which may injure perilaryngeal tissue, such as the piriform recess, the epiglottic vallecula, etc. If the tip of a lightwand reaches the glottis, the device would cause damage to the vocal cords. In fact, postoperative hoarseness was found more often in the lightwand technique groups. Therefore, although stimulation by lightwand-assisted intubation would not be strong enough to cause a hyperdynamic response in normotensive patients, it is sufficient to produce hypertension in hypertensive patients.
The magnitude of stimuli to the upper airway depends on the number of attempts and the duration of intubation. The lightwand technique needed significantly more attempts, and consequently, a longer duration for intubation than the laryngoscopic technique. In hypertensive patients, a significant correlation was found between the hemodynamic changes and the number of attempts at intubation (P < 0.05). This result suggests that hypertension after the lightwand-assisted intubation might be attenuated, if the first attempt at intubation is smooth.
In summary, the lightwand technique required significantly more attempts and a longer time-to-intubation than the laryngoscopic technique in both normotensive and hypertensive patients. However, the lightwand technique significantly attenuated hemodynamic changes to intubation in comparison with the laryngoscopic technique in normotensive patients, and in hypertensive patients there were no differences in hemodynamic changes between the two techniques.
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