Anaesthesia, 2009, 64, pages 13031306 doi:10.1111/j.1365-2044.2009.06106.x .....................................................................................................................................................................................................................

A comparison of a exometallic tracheal tube with the intubating laryngeal mask tracheal tube for nasotracheal breoptic intubation using the two-scope technique*
M. R. Rai, S. H. Scott, A. G. Marn, M. T. Popat and J. J. Pandit
Consultants, Nufeld Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK Summary

We compared the incidence and site of impingement of a exometallic tracheal tube with those of the re-usable intubating laryngeal mask (ILMA) tube in 60 anaesthetised patients undergoing nasotracheal breoptic intubation for oral surgery. A two-scope technique was used, observing the site of impingement with one scope whilst intubating with the other. The tubes were 6.0-mm in females and 6.5-mm in males. Impingement occurred with 10 (33%) exometallic and 2 (7%) ILMA tubes (p < 0.032). In all but one case, the impingement was posterior to the right arytenoid cartilage. When impingement was observed, a single disempaction with a 90 anticlockwise rotational manoeuvre overcame impingement in every case except one, allowing successful intubation. We conclude that the incidence of impingement of the tracheal tube, and therefore of potential laryngeal trauma from nasotracheal breoptic intubation, is signicantly greater with the exometallic tube than with the ILMA tube.
. ......................................................................................................

Correspondence to: Dr A. G. Marn E-mail: alex.marn@tiscali.co.uk *Presented in part at the Annual Meeting of the European Society of Anaesthesiology, Madrid, Spain; June 2006. Accepted: 5 August 2009

Laryngeal impingement of tracheal tubes during breoptic intubation is a common cause of failure to intubate using this technique and a potential cause of laryngeal trauma. Previous studies have found impingement rates of 4090% for oral and nasal intubation [18]. Several factors can inuence impingement: the route of intubation; tracheal tube characteristics such as size and design; and rotational manoeuvres [13]. Flexometallic tubes have been reported to have a low incidence of impingement for oral and nasotracheal intubation (35 40%) [46]. More recently, studies have demonstrated advantages of intubating laryngeal mask airway (ILMA) tubes for breoptic intubation [68]. However, these studies compared the incidence of impingement either for oral breoptic intubation or for nasotracheal intubation using larger tracheal tubes of internal diameter > 6.5 mm. The ILMA tube is now available in sizes of 6.0 and 6.5 mm which are more suitable for nasotracheal breoptic intubation. We wanted to determine the rate of impingement for the smaller sized
2009 The Authors Journal compilation 2009 The Association of Anaesthetists of Great Britain and Ireland

tubes, comparing the exometallic tube with the ILMA tube. We also aimed to assess the site of impingement using a two-scope technique, as passage of different designs of tracheal may be obstructed by different laryngeal structures.
Methods

Following research ethics committee approval and written informed consent, we recruited 60 patients of ASA physical status 1-2, aged 1865. All patients were scheduled to undergo elective dental or maxillofacial surgery under general anaesthesia for which nasotracheal intubation was indicated. The Mallampati test, thyromental distance, jaw protrusion and neck movement were used to assess the airway. If three out of the four tests predicted a difcult airway, the patients were excluded from the study. Patients were randomly assigned using group identiers hidden within opaque sealed envelopes to receive either a exometallic tube (Mallinckrodt
1303

M. R. Rai et al. Comparison of exometallic vs ILMA tube for impingement Anaesthesia, 2009, 64, pages 13031306 . ....................................................................................................................................................................................................................

Medical, Althone, Ireland) or a reusable ILMA tube (Laryngeal Mask Company, Henley-on-Thames, UK). After connecting routine monitoring, all patients received glycopyrronium 200 lg IV at the start of the procedure. Following pre-oxygenation for 3 min, anaesthesia was induced using midazolam 2 mg, fentanyl 12 lg.kg)1 and propofol 23 mg.kg)1. Neuromuscular blockade was established with atracurium 0.5 mg.kg)1 and conrmed with a peripheral nerve stimulator. The patients lungs were ventilated with 100% oxygen and 12% isourane. Xylometazoline drops were instilled in each nostril. Every case in the study was managed by at least two of the investigators at any one time, all being experienced in the technique of breoptic intubation. Both brescopes used in the study were Storz exible brescopes (4.0 mm OD, 60 cm length; Karl Storz Endoscopy Inc., Tuttlingen, Germany). Once the patient was anaesthetised, a breoptic scope was inserted into each nostril (as is our regular practice for any breoptic intubation). The smaller nostril was chosen for the observing scope and the larger nostril for the intubating scope. With the patient supine, the rst brescope attached to a closed circuit television screen (CCTV) was inserted through smaller of the two nostrils and the tip of the scope aligned to provide a clear view of the supraglottic region. This was the observing brescope operated by the observing anaesthetist. The relevant tracheal tube (6.0-mm in females, 6.5-mm in males) was preloaded on to a second brescope in a standardised non-rotated position (i.e. with the leading edge of the tube facing to the right and bevel to the left). The intubating anaesthetist then proceeded to perform a conventional nasal breoptic endoscopy with the intubating brescope attached to a second CCTV screen. Once the carina was seen on the screen, the tracheal tube was railroaded over the brescope and tracheal intubation attempted. The intubating anaesthetist noted any resistance to passage of the tracheal tube through the larynx and performed rotational manoeuvres for up to three attempts. With each attempt, if impingement occurred, the site of hold up was noted by the observing anaesthetist. If impingement of the tube occurred during the rst attempt, the intubating anaesthetist withdrew the tube by 2 cm and rotated it anticlockwise by 90 and re-attempted intubation. If impingement occurred at the second attempt, the tube was again withdrawn and rotated a further 90 anticlockwise. If impingement occurred at the third attempt, in addition to further 90 anticlockwise rotations, the anaesthetic assistant was asked to apply cricoid pressure. The observing anaesthetist also recorded the data during the procedure. The endpoint was observation of the passage of the tube into the trachea.
1304

If intubation took longer than 2 min or if the patients oxygen saturation fell below 95%, the intubating anaesthetist stopped the procedure and ventilated the patients lungs with 100% oxygen with isourane via a facemask. Patients were given intermittent boluses of propofol 3050 mg if there was any suggestion of decreasing depth of anaesthesia during the breoptic intubation process. If intubation was unsuccessful after three attempts, the brescopes were removed and the tracheal tube inserted under direct vision with the aid of a Macintosh laryngoscope and Magills forceps. In summary, we recorded the site of impingement on the larynx, the estimated degree of the rotation transmitted to the distal tip of the tube, and the number of attempts required for intubation. The exometallic tube has a rst-time reported impingement rate of around 40% and previous studies indicated an impingement rate of 010% for the ILMA tube. Thus to demonstrate at least this difference, a power calculation indicated that 30 patients per group were required to show with 80% power a signicant difference (p < 0.05) in the impingement rate between the two groups. Statistical analysis was done using SPSS 15.0 for Windows software. We used the chi-squared test to compare the incidence of impingement between the two groups.
Results

Table 1 shows that characteristics were similar between patient groups with respect to age, body mass index (BMI), airway assessment, tube size and side of intubation. There were slightly more male patients in the exometallic group than in the exometallic group. The incidence of impingement at the rst attempt was ve times higher with the exometallic tube than with the ILMA tube (p < 0.032) (Table 2). In nine of the 10 patients with impingement in the exometallic group and

Table 1 Characteristics of patients whose tracheas were intubated with the exometallic or ILMA tubes. Values are mean (SD) or number (proportion).
Flexometallic (n = 30) Age; years Sex; M:F ASA grade 1 2 3 Body mass index; kg.m)2 Nostril used R:L 30 (9) 15:15 21 (70%) 8 (27%) 1 (3%) 26 (4) 14:16 ILMA (n = 30) 32 (14) 21:9 24 (80%) 6 (20%) 0 24 (5) 13:17

2009 The Authors Journal compilation 2009 The Association of Anaesthetists of Great Britain and Ireland

Anaesthesia, 2009, 64, pages 13031306 M. R. Rai et al. Comparison of exometallic vs ILMA tube for impingement . ....................................................................................................................................................................................................................

in both patients in the ILMA group, the trachea was intubated at the second attempt. One of the patients in the exometallic group required a third attempt to complete intubation. There was no instance of complete failure to intubate in either group. There were no adverse events such as episodes of desaturation, bradycardia or laryngeal trauma. In all cases the observing anaesthetist was able to obtain an unobstructed view of the intubating brescope and patients had no bleeding which may have potentially obstructed the view. In all but one case, the site of impingement was the posterior part of the right arytenoid cartilage. Only once (in the exometallic group), the right aryepiglottic fold was the site of hold up. After a disempaction by withdrawing the tube, the rotation of the distal tip of the tube seemed to match the degree of rotation applied at the proximal end of the tube in all cases. Only in one case was more than a 90 anticlockwise rotation required to overcome impingement. No cases of impingement on the epiglottis or vocal cords were observed in either group (Table 2).
Discussion

The main nding of our study is a signicantly lower incidence of impingement with the ILMA tube compared with the exometallic tube at the rst pass. This study also conrms that the right supraglottic structures are more likely sites for a laryngeal hold-up [1, 9, 10]. Ours appears to be the rst study to report on the incidence as well as the site of impingement with the use of re-usable nasal ILMA tubes. One of the perceived limitations of our study may be the lack of blinding. Previous studies have covered the breoptic scope and the tracheal tube with a disposable

Table 2 Incidence and site of impingement, and the correctional manoeuvres successful in overcoming impingement, during tracheal intubation with the exometallic and ILMA tubes. Values are number (proportion).
Flexometallic (n = 30) ILMA (n = 30)

Groups Incidence of impingement First pass Second pass Site of impingement Right posterior arytenoid cartilage Right lateral arytenoid cartilage Correctional manoeuvres 90 anticlockwise 180 anticlockwise

10 30 (33%) 1 10 (10%) 9 10 (90%) 1 10 (10%)

2 30 (6%) 2 2 (100%)

9 10 (90%) 1 10 (10%)

2 2 (100%)

paper towel to blind the intubating anaesthetist to the selection of tracheal tube [6, 7]. In our study, though, blinding would not have been possible with the twoscope technique used. However, lack of blinding should not have caused any investigator bias, as with the twoscope technique the incidence of impingement is based on observation of the hold-up, as opposed to a subjective, observer-dependent scoring system. Impingement of the tracheal tube during breoptic intubation is important as it can cause trauma to the larynx and bleeding in the airway, and can eventually result in failed intubation. Several studies have compared different designs of tracheal tubes for breoptic intubation in an attempt to identify a design that would minimise this problem. The right arytenoid cartilage has been reported as the most common site of impingement of the tubes tip and we have demonstrated this in a previous study using a two-scope technique [9]. The ILMA tube design lends itself to reducing the incidence of impingement during what is essentially a blind part of breoptically assisted intubation. It has a bevel that is made of silicone rubber and is soft and hemispherical, with the leading edge in the midline. Three previous studies have reported an impingement rate for ILMA tubes ranging from 0 to 10% [68]. Two of these studies compared the incidence of impingement for the ILMA tube for oral breoptic intubation [7, 8]. We wished to determine if their results could be extended to nasal breoptic intubations as suggested by Lucas & Yentis [8]. A third study by Barker et al. [6] demonstrated a 100% rst-pass success for railroading of the ILMA tube over the breoptic scope for nasotracheal breoptic intubation. However, we felt that there were two main limitations to Barker et al.s study. One was the comparison of ILMA tracheal tubes of internal diameter 7.0 mm with exometallic tubes of 6.5 mm, and the second was the evaluation of impingement by an observer-dependent classication system. This has the disadvantage of being subjective and also is unable to identify the site of impingement or the efcacy of correctional manoeuvres. We designed our study protocol to overcome these limitations and the two-scope method allowed us to observe the impingement when it occurred, to determine whether the different design of the ILMA tubes tip resulted in impingement at sites other than the arytenoid cartilage and to observe the efcacy of correctional manoeuvres. It is interesting that impingement occurred more often at posterior rather than lateral laryngeal structures, and it is also notable that in all but one case, a single rotational manoeuvre was required to overcome the hold-up. This highlights another important issue: whether pre-rotation of the standard exometallic tube by )90 before railroading may reduce the incidence of impingement, such
1305

2009 The Authors Journal compilation 2009 The Association of Anaesthetists of Great Britain and Ireland

M. R. Rai et al. Comparison of exometallic vs ILMA tube for impingement Anaesthesia, 2009, 64, pages 13031306 . ....................................................................................................................................................................................................................

that the potential benets of the ILMA tube may be surpassed. A previous study by Hughes and Smith [11] demonstrated signicantly a lower incidence of impingement for nasal breoptic intubation when the tube was pre-rotated by 90180 before advancement. However, at present there are not enough data to suggest that there is a denite and predictable advantage of pre-rotation. Therefore, future studies on laryngeal impingement will require the rotational orientation of the tube to be explicitly described and controlled. While the ILMA tube appears to be superior to the exometallic and to most of the commonly used designs of tracheal tubes for breoptic intubation [12], it may also have certain disadvantages. The high pressure low volume cuff of the ILMA tube may be a drawback if the patient requires the tracheal tube in situ for a longer time e.g. the postoperative period in the intensive care unit after major head and neck surgery. The higher cost of an ILMA tube may be considered a disadvantage, as may the fact that the ILMA tube is re-usable. Single-use ILMA tubes are now available, but whether they will perform as well as the re-usable version remains to be seen. However, in selecting equipment that will improve the chances of successful breoptic intubation at the rst attempt, it appears that the ILMA tube offers signicant advantages.
References 1 Asai T, Shingu K. Difficulty in advancing a tracheal tube over a fibreoptic bronchoscope. Incidence, causes and solutions. British Journal of Anaesthesia 2004; 92: 87081. 2 Ovassapian A, Yelich SJ, Dykes MHM, Brunner EE. Fibreoptic nasotracheal intubation. Incidence and causes of failure. Anaesthesia and Analgesia 1983; 62: 6925.

3 Jones HE, Pearce AC, Moore P. Fibreoptic intubation. Influence of tracheal tube tip design. Anaesthesia 1993; 48: 6724. 4 Brull SJ, Wiklund R, Ferris C, Conelly NR, Ehrenwerth J, Silverman DG. Facilitation of fibreoptic orotracheal intubation with a flexible tracheal tube. Anesthesia and Analgesia 1994; 78: 7468. 5 Hakala P, Randell T, Valli H. Comparison between tracheal tubes for orotracheal fibreoptic intubation. British Journal of Anesthesia 1999; 82: 1356. 6 Barker KF, Bolton P, Cole S, Coe PA. Ease of laryngeal passage during fibreoptic intubation: a comparison of three endotracheal tubes. Acta Anaesthesiologica Scandinavica. 2001; 45: 6246. 7 Greer JR, Smith SP, Strang T. A comparison of tracheal tube tip designs on the passage of an endotracheal tube during oral fibreoptic intubation. Anesthesiology 2001; 94: 72931. 8 Lucas DN, Yentis SM. A comparison of the intubating laryngeal mask tracheal tube with a standard tracheal tube for fibreoptic intubation. Anaesthesia 2000; 55: 35861. 9 Marfin AG, Iqbal R, Mihm F, Popat MT, Scott SH, Pandit JJ. Determination of the site of tracheal tube impingement during nasotracheal fibreoptic intubation. Anaesthesia 2006; 61: 64650. 10 Johnson DM, From AM, Smith RB, From RP, Maktabi MA. Endoscopic study of mechanisms of failure of endotracheal tube advancement into the trachea during awake fibreoptic orotracheal intubation. Anesthesiology 2005; 102: 9104. 11 Hughes S, Smith JE. Nasotracheal tube placement over the fibreoptic laryngoscope. Anaesthesia 1996; 51: 10268. 12 Kihara S, Komatsuzaki T, Brimacombe JR, Yaguchi Y, Taguchi N, Watanabe S. A silicone-based wire-reinforced tracheal tube with a hemispherical bevel reduces nasal morbidity for nasotracheal intubation. Anesthesia and Analgesia 2003; 97: 148891.

1306

2009 The Authors Journal compilation 2009 The Association of Anaesthetists of Great Britain and Ireland