Tracheal intubation with the McGrath MAC X-blade videolaryngoscope in morbidly obese and nonobese patients

Background/aim: Increased body mass index (BMI) and neck circumference are the two independent predictors of difficult intubation.McGrath MAC X-Blade is a videolaryngoscope specifically designed for difficult intubations.Materials and methods: Eighty patients with the American Society of Anesthesiologists (ASA) physical status I–III undergoing electivesurgery requiring endotracheal intubation were enrolled in the study. Patients were divided into two groups, nonobese (BMI < 30) andmorbidly obese (BMI > 35). All patients were intubated with the McGrath MAC X-Blade in both groups. View optimization and tubeinsertion maneuvers such as reinsertion of the device, slight removal of the device, cricoid pressure, handling force, 90° anticlockwiserotation of the tube, use of stylet, and head flexion maneuvers were recorded. Cormack–Lehane grades, insertion times, intubation, andtotal intubation times were recorded. The hemodynamic changes and postoperative minor complications were also recorded.Results: Body mass index, neck circumference, Mallampati scores, and ASA physical status were statistically higher in the morbidlyobese group (P < 0.001 and P < 0.05). Sternomental distances were shorter in the morbidly obese (P < 0.05). Cormack–Lehane gradeswere comparable among the groups. The morbidly obese patients required more reinsertion attempts and cricoid pressure maneuversduring intubation than the nonobese patients (P = 0.019 versus P = 0.012, respectively). Slight removal of the device, handling force,use of the stylet, 90° anticlockwise rotation of the tube, and head flexion maneuvers were also helpful in both groups. Although deviceinsertion times were similar between the groups, intubation and total intubation times were longer in the morbidly obese group (P =0.009 and P = 0.034, respectively). The groups were comparable in hemodynamic changes and postoperative minor complications.Conclusion: The McGrath MAC X-Blade videolaryngoscope could safely be used both in nonobese (BMI < 30) and morbidly obese(BMI > 35) patients with the aid of some key maneuvers and with a statistically significant but clinically negligible prolongation of theintubation time.

PDF

___

1. Cook TM, Woodall N, Harper J, Benger J. Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. British Journal of Anaesthesia 2011; 106: 632-642.
2. Dixit A, Kulshrestha M, Mathews JJ, Bhandari M. Are the obese difficult to intubate? British Journal of Anaesthesia 2014; 112: 770-771.
3. Riad W, Vaez MN, Raveendran R, Tam AD, Quereshy FA et al. Neck circumference as a predictor of difficult intubation and difficult mask ventilation in morbidly obese patients: A prospective observational study. European Journal of Anaesthesiology 2016; 33: 244-249.
4. Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R et al. Difficult Airway Society intubation guidelines working group. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British Journal of Anaesthesia 2015; 115: 827-848.
5. Law JA, Broemling N, Cooper RM, Drolet P, Duggan LV et al. Canadian Airway Focus Group. The difficult airway with recommendations for management – Part 1 – difficult tracheal intubation encountered in an unconscious/induced patient. Canadian Journal of Anaesthesia 2013; 60: 1089-1118.
6. Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT et al. American Society of Anesthesiologists Task Force on management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on management of the difficult airway. Anesthesiology 2013; 118: 251-270.
7. Dhonneur G, Abdi W, Ndoko SK, Amathieu R, Risk N et al. Video-assisted versus conventional tracheal intubation in morbidly obese patients. Obesity Surgery 2009; 19: 1096-1101.
8. Kelly FE, Cook TM. Seeing is believing: getting the best out of videolaryngoscopy. British Journal of Anaesthesia 2016; 117 Suppl 1: i9-i13.
9. Lafferty BD, Ball DR, Williams D. Videolaryngoscopy as a new standard of care. British Journal of Anaesthesia 2015; 115: 136-137.
10. Zauter C, Calderon J, Hemmerling TM. Videolaryngoscopy as a new standard of care. British Journal of Anaesthesia 2015; 114: 181-183.
11. Arslan ZI, Alparslan V, Ozdal P, Toker K, Solak M. Faceto-face tracheal intubation in adult patients: a comparison of the Airtraq, Glidescope and Fastrach devices. Journal of Anesthesia 2015; 29: 893-898.
12. Yumul R, Elvir-Lazo OL, White PF, Sloninsky A, Kaplan M et al. Comparison of three video laryngoscopy devices to direct laryngoscopy for intubating obese patients: a randomized controlled trial. Journal of Clinical Anesthesia 2016; 31: 71-77.
13. Lee J, Kwak HJ, Lee JY, Chang MY, Lee SY et al. Comparison of the Pentax AirwayScope and McGrath MAC videolaryngoscope for endotracheal intubation in patients with a normal airway. Medicine 2017; 96: e8713.
14. Juvin P, Lavaut E, Dupont H, Lefevre P, Demetriou M et al. Difficult tracheal intubation is more common in obese than in lean patients. Anesthesia and Analgesia 2003; 97: 595-600.
15. Yakushiji H, Goto T, Shirasoko W, Hagiuana Y, Watase H et al. Japanese emergency medicine network investigators. Associations of obesity with tracheal intubation success on first attempt and adverse events in the emergency department: An analysis of the multicenter prospective observational study in Japan. PLoS One 2019; 13: e0195938.
16. Hoshijima H, Denawa Y, Tominaga A, Nakamura C, Shiga T et al. Videolaryngoscope versus Macintosh laryngoscopy for tracheal intubation in adults with obesity: A systematic review and meta-analysis. Journal of Clinical Anesthesia 2018; 44: 69- 75.
17. Marrel J, Blanc C, Frascarolo P, Magnusson L. Videolaryngoscopy improves intubation condition in morbidly obese. European Journal of Anaesthesiology 2007; 24: 1045-1049.
18. Pieters BMA, Maas EHA, Knape JTA, van Zundert AAJ. Videolaryngoscopy vs. direct laryngoscopy use by experienced anaesthetists in patients with known difficult airways: a systematic review and meta-analysis. Anaesthesia 2017; 72: 1532-1541.
19. Hyuga S, Sekiguchi T, Ishida T, Yamamoto K, Sugiyama Y et al. Successful tracheal intubation with the McGrath MAC videolaryngoscope intubation with the McGrath MAC videolaryngoscope after failure with the Pentax-AWS in a patient with cervical spine immobilization. Canadian Journal of Anaesthesia 2012; 59: 1154-1155.
20. Thion LA, Belze O, Fischler M, Guen ML. Comparison of the ease of tracheal intubation using a McGrath MAC videolaryngoscope and a standard Macintosh laryngoscope in normal airways: A randomized trial. European Journal of Anaesthesiology 2018; 35: 631-633.
21. Alvis BD, Hester D, Watson D, Higgins M, Jacques P. Randomized controlled trial comparing the McGrath MAC videolaryngoscope with the King Vision videolaryngoscope in adult patients. Minerva Anestesiologica 2016; 82: 30-35.
22. Gaszynski T. The visualization of glottis during intubation’s efforts in super obese patients: a comparison of total track video intubating laryngeal mask and McGarth MAC videolaryngoscope. Journal of Clinical Monitoring and Computing 2017; 31: 1329-1332.
23. Chung MY, Park B, Seo J, Kim CJ. Successful airway management with combined use of McGrath MAC videolaryngoscope and fiberoptic bronchoscope in a severe obese patient with a huge goiter – a case report. Korean Journal of Anesthesiology 2018; 71: 232-236.
24. Yildiz TS, Ozdamar D, Arslan I, Solak M, Toker K. The LMA CTrach in morbidly obese and lean patients undergoing gynecological procedures: a comparative study. Journal of Anesthesia 2010; 24: 849-853.
25. Dhonneur G, Ndoko SK, Amaethieu R, Attias R, Housseini LE et al. A comparison of two techniques for inserting the Airtraq laryngoscope in morbidly obese. Anaesthesia 2007; 62: 774- 777.
26. Gaszynski T. Comparison of the glottis view during video-intubation in super obese patients: a series of cases. Therapeutics and Clinical Risk Management 2016; 12: 1677- 1682.
27. Arslan ZI, Solak M. Effect of cricoid pressure on laryngeal view during Macintosh, McGrath MAC X-Blade and GlideScope video laryngoscopies. Turkish Journal of Anaesthesiology and Reanimation 2017; 45: 361-366.
28. Dhonneur G, Abdi W, Amathieu R, Ndoko S, Tual L. Optimising tracheal intubation success rate using the Airtraq laryngoscope. Anaesthesia 2009; 64: 315-319.
29. Xue FS, Liu GP, Sun C. Use of a 90-degree anticlockwise tube rotation to facilitate nasotracheal tube passage over the fiberscope into the trachea in pediatric patients. Paediatric Anaesthesia 2016; 26: 565-566.
30. Sato Boku A, Sobue K, Kako E, Tachi N, Okumuro Y et al. The usefulness of the McGrath MAC laryngoscope in comparison with AirwayScope and Macintosh laryngoscope during routine nasotracheal intubation: a randomized controlled trial. BMC Anesthesiology 2017; 17: 160.
31. Altun D, Ali A, Çamcı E, Özonur A, Seyhan TÖ. Haemodynamic response to four different laryngoscopes. Turkish Journal of Anaesthesiology and Reanimation 2018; 46: 434-440.