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Anesth Analg 2004;99:279-283 © 2004 International Anesthesia Research Society doi: 10.1213/01.ANE.0000118103.78553.06
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Abstract |
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In some situations, patients need endotracheal intubation to maintain airway patency while they are constrained in the lateral position. In this study we compared lightwand-guided intubation of 120 randomly enrolled patients placed in the supine, right, or left lateral position. Group S patients were initially placed in the supine position, and subsequent to the artificial airway having been established they were turned to the lateral decubitus position. Group R patients were initially placed in a right decubitus position during induction and intubation. Group L patients were initially placed in a left decubitus position during induction and intubation. The duration of each intubation attempt, the total time to successful intubation, and the incidence of intubation-related intraoral injury, hemodynamic changes, and postoperative sore throat and hoarseness were recorded. Intubation took a similar length of time in the supine (14.5 ± 13.4 s), left lateral (13.3 ± 10.2 s), and right lateral positions (15.5 ± 13.0 s) and resulted in a similar trend in hemodynamic changes. Patients in the lateral and supine positions revealed a comparable incidence of successful first-attempt intubation, sore throat, hoarseness, oral mucosal injury, and dysrhythmia. Insignificantly more esophageal intubations were performed in the lateral position in the first attempt at intubation; however, all patients were correctly intubated shortly after reattempting intubation. We concluded that lightwand-assisted intubation is easily performed and a similar technique may be used whether the patient is in a lateral, recumbent, or a supine position. This alternative technique should be practiced and is recommended for patients who must remain in a lateral position during intubation and surgery.
IMPLICATIONS: The skilled anesthesiologist can easily and effectively perform a lightwand-assisted intubation for patients in a lateral position. This alternative technique should be practiced before attempting it for the first time, and it is recommended for patients who must remain in a lateral position.
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Introduction |
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During surgery, the anesthesiologist must be skilled in airway management to cope with a sudden accidental loss of airway patency, airway obstruction from vomitus, or serious cardiopulmonary compromise. On some occasions, patients who suffer these conditions need to be tracheally intubated with an endotracheal tube (ETT) to maintain airway patency as soon as possible, even when the patient is not in a supine position. Direct laryngoscopic endotracheal intubation is a standard technique to rapidly establish a patent airway for a supine patient, although tracheal intubation in the lateral position may be necessary for some patients under certain circumstances. Tracheal intubation under direct vision in the lateral decubitus position has proven more difficult. On average, more attempts at intubation are required to achieve effective intubation for patients in the lateral decubitus position as compared with patients in the supine position due, principally, to the distorted patient-airway anatomy and the uncomfortable, often unfamiliar, posture necessarily required of medical personnel (1). To establish reliable ventilation, an intubating laryngeal mask airway (ILMA) has been successfully used to assist a lightwand-guided intubation technique for patients lying in the supine or lateral position, although this procedure is complicated and not recommended for inexperienced practitioners (2–4). Successful intubation using only a lightwand device (Trachlight), even for anesthetized patients using (unanticipated) failed laryngoscopic intubation, has been confirmed by a number of studies (5,6). For patients with cervical spine disorders, the Trachlight-assisted orotracheal intubation procedure may be more reliable, more expeditious and safer than the ILMA technique (7). There are no published data pertaining to the use of Trachlight-guided intubation for patients constrained in the lateral decubitus position. Therefore, in this study we investigated lightwand-guided intubation (performed by a skilled anesthesiologist) and compared the effects of such intubation for patients lying in the supine, right, and left lateral positions.
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Methods |
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The Kaohsiung Medical University ethics committee approved this study prospectively, and written informed consent was requested and obtained from all participating patients. One-hundred-twenty ASA physical status I–II adult patients scheduled for elective orthopedic surgery in the lateral decubitus position and for whom endotracheal intubation for general anesthesia had been suggested were enrolled into this study and allocated randomly into one of three different patient groups. Patients revealing poor oral hygiene, coronary-artery disease, hypertension, cerebrovascular disorders, and those with a known history of a previous difficult tracheal intubation, or those with a history of surgery conducted in the pharyngeal or laryngeal region or cervical spine were excluded from this study.
All patients were required to fast for at least 8 h before surgery, and no premedication was given. On arrival in the operating room, patients were monitored with an electrocardiograph lead II for measuring heart rate (HR). A local anesthetic (1% lidocaine) was injected intradermally using a 26-gauge needle, after which a 22-gauge catheter was inserted into a radial artery to permit continuous recording of systolic and diastolic arterial blood pressures. The initial anesthetic induction was by IV fentanyl (2 µg/kg), atracurium (0.5 mg/kg), and thiopental (5 mg/kg), and manual ventilation was administered for 3 min via a mask before oral, Trachlight-guided intubation under reduced ambient light. The distal end of the ETT and lightwand unit was shaped into a "hockey stick" configuration that placed the lightbulb close to, but not protruding beyond, the tip of the ETT. An inhaled anesthetic of isoflurane was administered and the end-tidal isoflurane concentration was kept within the range of 2
2.5% to maintain a stable depth of anesthesia. The end-tidal CO2 concentration was maintained in the range of from 3540 mm Hg with adjustment of respiratory frequency approximately 8 to 10 times per minute and with a tidal volume of 1012 mL per kilogram being maintained during the study period. For Group S, patients were placed in a supine position with their head and neck maintained in the neutral or relatively extended position with a pillow and the epiglottis being lifted with a simple jaw-lift maneuver during intubation. Subsequent to the artificial airway having been established these patients were turned into a lateral decubitus position for the duration of the surgical procedure. For Group R, patients were placed in a right decubitus position during induction and intubation. For Group L, patients were placed in a left decubitus position during induction and intubation. A pillow, together with a sheet beneath the underside of the head and neck, was used to maintain the axial alignment, and both arms were placed perpendicular to the torso over the armrest in order to support the weight. During intubation for patients lying in the lateral position, the patient’s head and neck were placed in a neutral or extended position, and the epiglottis was lifted with a simple jaw-lift maneuver during intubation.
Three intubations were attempted if necessary. Failure of intubation was defined as the inability to effectively intubate after three attempts, at which point the classic laryngeal mask airway (LMA) was inserted to maintain the airway patency. The duration of each intubation attempt was recorded as the time from the introduction of the intubation unit into the oral cavity to the time of wand removal from the tracheal tube. The total time to intubation was defined as the sum of the duration of all intubation attempts. After tracheal intubation had been completed, the oropharynx was examined by another anesthesiologist for evidence of complications, such as oral mucosal bleeding, lacerations, and/or dental injury.
Mean arterial blood pressure (MAP) and HR were recorded at the following time intervals: (BA) before anesthetic induction, (T1) 1 min after tracheal intubation, (T2) 2 min subsequent to tracheal intubation, (T3) 3 min after tracheal intubation, and (T5) 5 min subsequent to tracheal intubation. A stopwatch was used to measure the time taken to insert a tracheal tube.
At the completion of surgery and anesthesia, the ETT was removed using routine extubation criteria (8). All perioperative side effects and complications were recorded, and on the morning of the next day, patients were asked by medical personnel, blinded as to the procedure, about any dryness of mouth, sore throat, or hoarseness.
The time required for intubation and the number of successful attempts among the three study groups were tested by analysis of variance. Side effects and complications among groups were compared using a 
2 test. MAP and HR were determined for all study participants during the periintubation period, the results corresponding to the three different study groups being compared using repeated-measures analysis of variance.
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Results |
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The three groups were matched with respect to age, body weight, height, gender distribution, and presenting diseases necessitating surgery. For all these variables, no statistically significant difference was noted among the three groups (Table 1). Intubation was of a similar duration for patients lying in the supine, left lateral, and right lateral positions. Four patients from Group S, three patients from Group L, and three patients from Group R required reintubation after an unsuccessful first attempt at intubation. Among these, those patients lying in a lateral position experienced more attempted esophageal intubations, although the difference in the number of intubations required for the different groups was not statistically significant (Table 2).
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Measurement of the hemodynamic changes that occurred for the three groups during the periintubation period revealed a similar MAP and HR trend for Groups S, L, and R. Compared with the situation of BA, the time interval, MAP increased rapidly during the time interval from T1 to T2, it then gradually declined to a comparable range by time point T3, and then decreased more obviously by time point T5. There was a statistically significant difference between the BA time interval and the T1 (P < 0.0001), T2 (P < 0.0001), and T5 (P < 0.001) time intervals, apart from the BA and T3 (P = 0.28) time intervals. The trend in HR was similar to the trend in MAP, with statistical significance being apparent in the comparison between the BA time interval and the T1 (P < 0.0001), T2 (P < 0.0001), T3 (P < 0.0001), and T5 (P < 0.001) time intervals (Table 3).
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An analysis of the side effects and complications associated with each of the three groups revealed a similar incidence in the severity of sore throat, dryness of mouth, hoarseness, and oral mucosal injury (Table 4). Six patients from Group S, four patients from Group L, and five patients from Group R experienced premature atrial contractions during intubation. These episodes were of a limited dimension and did not require medical intervention. Three patients from Group S, one patient from Group L, and three patients from Group R with cardiovascular complications suffered from premature ventricular contractions (PVC). Two of the three patients from Group S, one patient from Group L, and one of the three patients from Group R needed IV lidocaine (1 mg/kg) to block the sustained PVC.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Endotracheal intubation using direct laryngoscopy for patients in the lateral decubitus position may be an unfamiliar technique for anesthesiologists, and it is typically cumbersome and time-consuming as compared with the same procedure performed upon patients in the supine position. The difficulty with patients lying in the right lateral decubitus position is the positioning of the tongue, which (influenced by gravity) has a tendency to slip off the laryngoscope blade while the blade is being inserted from the right side of the tongue and moved centrally, upwards, there thus being a need to shift the tongue to the left side (9). From the results of this study, however, Trachlight-guided intubation proved to be a less complicated procedure in this regard, no matter whether the patients were lying in a supine, left lateral, or right lateral decubitus position. In addition, we noted no significant difference among groups regarding time to successful intubation, number of insertion attempts, hemodynamic changes that occurred during the intubation period, and the incidence of side effects and complications. These results suggest that Trachlight-assisted intubation can effectively establish airway patency regardless of the patient’s position at the time of intubation (i.e., supine or lateral).
Three patients from Group R and three patients from Group L were unintentionally esophageally intubated on the first attempt. We found that intubating patients in the lateral position may have been associated with an increase in the incidence of esophageal intubation as compared with patients lying in the supine position. It is critical that the glowing light spot emanating from the lightwand is seen on the anterior part of the neck because a blurred light spot arising from an intubated esophagus may easily be mistaken for light from the trachea when patients are positioned in a lateral position. In this study, it was relatively easy for our clinicians to differentiate the light in the trachea from that in the esophagus on the second or the third attempt at intubation. In the trachea, the produced light spot was revealed as a brilliant light point, with a focus on the anterior neck, although for the esophagus, the light appeared to be gloomy, with a diffuse character; it typically appeared to be focused on the mid-part of the neck. Further investigations are warranted to determine whether the more frequent incidence of esophageal intubation occurs among patients lying in the lateral position.
The classic LMA and ILMA techniques have frequently been used to attempt to maintain airway patency for patients with sudden accidental loss of the airway’s patency while lying in the lateral position. Improper LMA positioning, however, may result in unsatisfactory airway control by the anesthesiologist as a result of an airway leak developing during manual or mechanical ventilation (10,11). In addition, adequate ventilation via the ILMA and LMA techniques without the involvement of tracheal intubation have been reported to be only 77% and 56%, respectively (12). Although novice staff would likely find the technique of Trachlight-guided intubation more difficult to perform as compared with direct laryngoscopy, junior residents (in the first year of residency) who attempted the performance of Trachlight-guided intubation did reveal an overall intubation success rate of 92% and an overall average intubation time of about 42 seconds (13,14). Therefore, in more experienced hands, endotracheal intubation is a better ventilation option than LMA products for patients who are not lying in a supine position.
To overcome air leaks during controlled ventilation via use of an ILMA technique, as Choyce et al. (15) reported, 67% (52 of 75) of inexperienced personnel performed tracheal intubation via the ILMA successfully, whereas the attending investigator achieved a 95% success rate. Furthermore, Dimitriou et al. (2) and Dimitriou and Voyagis (4) demonstrated that experienced personnel could perform flexible lightwand-guided intubation via the ILMA for patients lying in the supine, left, and right lateral position with a high level of success. This technique, however, did incorporate two separate aspects: the initial insertion of the ILMA apparatus and the subsequent lightwand-guided intubation. Such procedures did, on occasion, present complications to clinical personnel who needed to promptly intubate certain patients who were not lying in a supine position. In this study, Trachlight-guided intubation was successfully performed virtually universally, the procedure requiring no previous ILMA insertion experience. In addition, Trachlight-guided intubation directly saves intubation time, as compared with the lightwand-guided intubation via ILMA. Therefore, Trachlight-guided intubation has been demonstrated to be a simple, safe, and timesaving technique for patients lying in the lateral position.
In summary, direct laryngoscopic intubation of patients lying in the lateral position may not be convenient, especially for patients with a sudden loss of patent airway. Trachlight-guided endotracheal intubation can be rapid and safe and can establish airway patency for patients lying in a number of different positions including the supine, left, or right lateral positions. Practice is required to become proficient at this technique, however, and this method should only be attempted by an experienced anesthesiologist to establish airway patency among patients with a sudden loss of airway control.
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References |
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- Nathanson MH, Gajraj NM, Newson CD. Tracheal intubation in a manikin: comparison of supine and left lateral positions. Br J Anaesth 1994; 73: 690–1.
[Abstract/Free Full Text] - Dimitriou V, Voyagis GS, Iatrou C, Brimacombe J. Flexible lightwand-guided intubation using the intubating laryngeal mask airway in the supine, right, and left lateral positions in healthy patients by experienced users. Anesth Analg 2003; 96: 896–8.
[Abstract/Free Full Text] - Dimitriou V, Voyagis GS, Brimacombe J. Detection and correction of accidental oesophageal intubation during flexible lightwand-guided intubation via the intubating laryngeal mask. Anaesth Intensive Care 2002; 30: 52–4.[Web of Science][Medline]
- Dimitriou V, Voyagis GS. Use of the intubating laryngeal mask for airway management and light-guided tracheal intubation in the lateral position. Eur J Anaesthesiol 2000; 17: 395–7.[Web of Science][Medline]
- Hung OR, Pytka S, Morris I, et al. Lightwand intubation: II–clinical trial of a new lightwand for tracheal intubation in patients with difficult airways. Can J Anaesth 1995; 42: 826–30.[Web of Science][Medline]
- Hung OR, Pytka S, Morris I, et al. Clinical trial of a new lightwand device (Trachlight) to intubate the trachea. Anesthesiology 1995; 83: 509–14.[Web of Science][Medline]
- Inoue Y, Koga K, Shigematsu A. A comparison of two tracheal intubation techniques with Trachlight and Fastrach in patients with cervical spine disorders. Anesth Analg 2002; 94: 667–71.
[Abstract/Free Full Text] - Stone DJ, Gal TJ. Airway management. In: Miller RD, ed. Anesthesia. 5th ed. New York: Churchill Livingstone. 2000: 1414–48.
- Cupitt JM. Induction of anaesthesia in morbidly obese patients. Br J Anaesth 1999; 83: 964–5.
[Free Full Text] - Chen CH, Lin CC, Tan PP. Clinical experience of laryngeal mask airway in lateral position during anesthesia. Acta Anaesthesiol Sin 1995; 33: 31–4.[Medline]
- Reissmann H, Pothmann W, Fullekrug B, et al. Resistance of laryngeal mask airway and tracheal tube in mechanically ventilated patients. Br J Anaesth 2000; 85: 410–6.
[Abstract/Free Full Text] - Choyce A, Avidan MS, Shariff A, et al. A comparison of the intubating and standard laryngeal mask airways for airway management by inexperienced personnel. Anaesthesia 2001; 56: 357–60.[Web of Science][Medline]
- Soh CR, Kong CF, Kong CS, et al. Tracheal intubation by novice staff: the direct vision laryngoscope or the lighted stylet (Trachlight)? Emerg Med J 2002; 19: 292–4.
[Abstract/Free Full Text] - Amornyotin S, Sanansilp V, Amorntien V, Tirawat P. Effectiveness of lightwand (Trachlight) intubation by 1st year anesthesia residents. J Med Assoc Thai 2002; 85: S963–8.
- Choyce A, Avidan MS, Patel C, et al. Comparison of laryngeal mask and intubating laryngeal mask insertion by the naive intubator. Br J Anaesth 2000; 84: 103–5.
[Abstract/Free Full Text]
This article has been cited by other articles:
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  V. Dimitriou, J. Brimacombe, G. S. Voyagis, and C. Iatrou Lightwand-Assisted Intubation of Patients in the Lateral Decubitus Position Anesth. Analg., April 1, 2005; 100(4): 1219 - 1219. [Full Text] [PDF]
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K.-I Cheng, K.-S. Chu, S.-W. Chau, and C.-S. Tang Lightwand-Assisted Intubation of Patients in the Lateral Decubitus Position Anesth. Analg., April 1, 2005; 100(4): 1219 - 1219. [Full Text] [PDF]
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