Anaesthesia, 2005, 60, pages 445448 .....................................................................................................................................................................................................................

A comparison of direct laryngoscopy and jaw thrust to aid breoptic intubation*

M. R. Stacey,1 S. Rassam,2 R. Sivasankar,2 J. E. Hall3 and I. P. Latto1
1 Consultant Anaesthetist, 2 Airway Research Associate and 3 Senior Lecturer, Department of Anaesthetics and Intensive Care Medicine, University Hospital of Wales, Cardiff, CF14 4XW, UK Summary

We compared two manoeuvres, jaw thrust and laryngoscopy, to open the airway during breoptic intubation in 50 patients after induction of anaesthesia in a crossover study. Patients were randomly allocated to receive either jaw thrust or conventional Macintosh laryngoscopy rst. Airway clearance was assessed at both the soft palate and the epiglottis. Direct laryngoscopy provided signicantly better airway clearance at the level of the soft palate than jaw thrust (44 (88%) vs 31 (62%), respectively; p = 0.002). At the level of the larynx, airway clearance was equally good in both groups (45 (90%) vs 46 (92%), respectively; p = 0.56). The times to view the larynx (median (interquartile range [range]) 4 (35 [235]) s vs 3 (34 [28]) s, respectively) and intubation time (20 (1723 [1183]) s vs 18 (1520 [1128]) s, respectively) were also similar.
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Correspondence to: M. R. Stacey E-mail: airwayman@doctors.org.uk *Presented in part at the AAGBIs Annual Congress, September 2004; Cardiff, UK. Accepted: 22 December 2004

Fibreoptic laryngoscopy may make easy an impossible or difcult intubation when using direct laryngoscopy. Pandit et al. [1] have achieved satisfactory success rates and orotracheal intubating times with the brescope in patients with grade-1 and grade-2 laryngoscopic views in simulated rapid sequence induction of anaesthesia. Fibreoptic intubation is an important method of tracheal intubation in both awake and anaesthetised patients [2]. A clear airway that allows the passage of the brescope is usually present in awake patients, whereas in anaesthetised patients the air space in the oropharynx is reduced; the soft palate, base of tongue and epiglottis may be applied to the posterior pharyngeal wall due to the reduction in muscle tone [36]. Hence, breoptic intubation may be difcult in anaesthetised patients, and manoeuvres to open the airway may be required. Airway clearance can be attempted using intubating aids such as Berman [7] or Ovassapian [8] airways; by applying jaw thrust with the mouth open; or by applying lingual traction. Jaw thrust and lingual traction applied alone do not necessarily clear the airway completely, but when applied together, have been shown to clear the airway [9]. The problem with these manoeuvres is that two assistants are required for successful performance. It
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has been shown that both lingual traction and the Berman airway methods of breoptic intubation cause a signicantly greater and more prolonged cardiovascular response than intubation using a Macintosh laryngoscope [10]. The airway clearance achieved by jaw thrust and lingual traction in combination may be achieved by Macintosh laryngoscopy with the added advantage that it requires only one assistant. Hence combining breoptic intubation with direct laryngoscopy may improve the ease of intubation. This study compared jaw thrust with laryngoscopy in producing airway clearance and aiding breoptic intubation.
Methods

The study protocol was approved by BroTaf Local Research Ethics Committee. Written informed consent was obtained from 50 adult patients of ASA physical status 12, scheduled to have elective operations requiring tracheal intubation. Patients were excluded if they had anatomical abnormalities causing potential difculties with airway management, respiratory insufciency, raised intracranial pressure, bleeding disorders or oesophageal reux.
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M. R. Stacey et al. Direct laryngoscopy vs jaw thrust Anaesthesia, 2005, 60, pages 445448 . ....................................................................................................................................................................................................................

Patients age, sex, weight, height, ASA grade, Mallampatti score and thyromental distance were recorded. Patients received oral premedication of 20 mg temazepam. In the anaesthetic room, an intravenous cannula was sited and monitoring with ECG, non-invasive blood pressure, pulse oximetry and capnography commenced. Following pre-oxygenation, anaesthesia was induced using 100 lg fentanyl and 1% propofol. Neuromuscular blockade was achieved with 0.50.75 mg.kg)1 atracurium and the lungs were ventilated using 2% isourane in 100% oxygen until neuromuscular blockade was complete, conrmed by absence of train-of-four elicited by a peripheral nerve stimulator. Patients were randomly allocated into two groups, with each group undergoing jaw thrust and laryngoscopy in a different order. Jaw thrust was performed by an experienced operating department assistant (all of whom were trained in the technique by the senior author) who stood facing the patient from the patients left side. The jaw thrust was performed by placing the ngers behind the posterior ramus of the mandible, with the thrust directed upwards and the thumbs opening the mouth. This is the method the senior author has used for the last 10 years to aid oral breoptic intubation under anaesthesia. Laryngoscopies were performed by an experienced anaesthetic trainee using a size-3 Macintosh laryngoscope blade. The patients laryngoscopic grade [11] was recorded. To minimise bias, all breoptic intubations were performed by one consultant anaesthetist with extensive experience in the technique who stood on the right side facing the patient. The monitor was at the patients head end. A exible brescope (Olympus LF-2 LF-GP, Key Medical Ltd, Essex, UK) connected to a camera and closed circuit television monitor was used. Video recordings were made of each procedure and viewed by a second consultant anaesthetist experienced in airway management who was blinded to the study, to conrm the observations of the operator. A Portex tracheal tube (8-mm ID in males, 7-mm in females) was railroaded over the brescope before endoscopy. After the rst manoeuvre, the operator advanced the brescope and airway clearance was assessed at the level of the soft palate and the epiglottis. The clearance was assessed according to a scoring system developed by Durga et al. [9]. If the uvula or part of the soft palate touched the tongue or if the sides of the epiglottis touched the posterior pharyngeal wall, the airway was considered to be partially obstructed at the respective level. The airway was considered fully obstructed at the respective level if the whole of the soft palate was in contact with the tongue or if the sides and tip of the epiglottis were in contact with the posterior pharyngeal wall. If the structures were not in contact, the airway was classied as clear. The brescope was then
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removed and the lungs ventilated. The second manoeuvre was then applied. Tracheal intubation was performed after completion of breoptic airway assessment of the second manoeuvre. Heart rate, BP and SpO2 were recorded at baseline immediately before applying the 1st manoeuvre; after brescopy (combined with the 1st manoeuvre), and after breoptic tracheal intubation (combined with the 2nd manoeuvre). Insertion time (time to view the larynx) was recorded in both groups as the brescope passed from the lips to the vocal cords (T1: time in the 1st manoeuvre and T2: time in the 2nd manoeuvre). The time when carbon dioxide appeared on the capnograph after intubation was also recorded (T3). The difference between T3 and T2 is the intubation time. A maximum of 90 s was allowed for the passage of the brescope; if the observations could not be completed in this time, the investigation was stopped and the trachea intubated by direct laryngoscopy. As this was a crossover study, the data obtained were analysed using the Wilcoxon signed rank test using the STATISTICAL PACKAGE for SOCIAL SCIENCES version 10 for Windows (SPSS Inc., Chicago, IL). A p-value of < 0.05 was considered signicant. Paired and unpaired Student t-tests were used to compare insertion time and intubation times within and between the two groups. Durga et al. [9] demonstrated that jaw thrust failed to clear the airway on seven occasions in 30 patients. Consequently, if laryngoscopy were to be 100% successful (as in combined jaw thrust and lingual traction) then 50 patients would be needed for a study with a power of 80% at the p < 0.05 level.
Results

We recruited seven males and 43 females. Their median [range] ages and weights were 58 [2284] years and 70 [46127] kg, respectively. Table 1 shows other characteristics including grade of laryngoscopy. The second anaesthetist reviewing the video recording of each procedure agreed with the initial assessment of view in 100% of cases. Airway clearance was signicantly better with direct laryngoscopy than with jaw thrust at the level of the soft palate, but similar at the level of the larynx (Table 2). Time to view the larynx (insertion time) and intubation time were also similar in the two groups. All patients tracheas were successfully intubated after the second manoeuvre that they were randomised to receive. Cardiovascular variables and SpO2 are shown in Table 3. There was no signicant increase in heart rate after intubation following either jaw thrust or direct laryngoscopy.
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Anaesthesia, 2005, 60, pages 445448 M. R. Stacey et al. Direct laryngoscopy vs jaw thrust . ....................................................................................................................................................................................................................

Table 1 Characteristics, pre-operative assessments and grades of

laryngoscopy in patients undergoing breoptic tracheal intubation using jaw thrust or direct laryngoscopy. Values are mean [range] or number (proportion).
Sex; M F Age; years Weight; kg ASA 1 ASA 2 ASA 3 Thyromental distance >6 cm <6 cm Mallampati I Mallampati II Mallampati III Cormack and Lehane Grade 1 Grade 2 Grade 3 7 43 58 [2284] 70 [46127] 7 (14%) 36 (72%) 7 (14%) 48 2 30 17 3 (96%) (4%) (60%) (34%) (6%)

40 (80%) 8 (16%) 2 (4%)

Table 2 Degree of obstruction and insertion intubation times

in 50 patients undergoing breoptic intubation with jaw thrust or direct laryngoscopy. Values are median (interquartile range [range]) or number (percentage).
Jaw thrust (n = 50) Level of the soft palate Total obstruction Partial obstruction Clear (no obstruction) Level of the larynx Total obstruction Partial obstruction Clear (no obstruction) Insertion time; s Intubation time; s* Laryngoscopy (n = 50)

p-value 0.002

5 (10%) 14 (28%) 31 (62%) 2 3 45 4 20 (4%) (6%) (90%) (35 [235]) (1723 [1183])

0 (0%) 6 (12%) 44 (88%) 0.564 1 3 46 3 18 (2%) (6%) (92%) (34 [28]) (1520 [1128])

0.093 0.141

*n = 25 in each group.

Table 3 Cardiovascular variables and arterial oxygen saturation

at baseline, at endoscopy (with jaw thrust or direct laryngoscopy) and after intubation. Values are mean (SD).
After intubation 90 (15) 97 (16) 99 (1)

Baseline Heart rate; beats.min)1 Mean BP; mmHg SPO2 80 (14) 94 (12) 99 (1)

Jaw thrust 82 (16) 87 (19) 99 (1)

Laryngoscopy 82 (18) 88 (21) 99 (1)

Discussion

Under general anaesthesia, posterior displacement of the tongue, soft palate and epiglottis tends to close the airway and may therefore cause difculty with breoptic
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intubation [5, 6]. The obstructed airway can be cleared using airways, jaw thrust, lingual traction or direct laryngoscopy [79, 12]. Durga et al. [9] demonstrated that combining jaw thrust and lingual traction cleared the airway more effectively (in 100% of 30 patients) than when either manoeuvre was used separately, though this technique required two assistants. In our study we used direct laryngoscopy to combine the effect of jaw thrust and lingual traction, with the advantage that only one assistant was required. Greenland et al. [13] compared the Williams Airway Intubator with the Ovassapian Fibreoptic Intubating Airway for bronchoscopic view and ease of railroading a tracheal tube during breoptic orotracheal intubation in a crossover trial of 60 patients. They reported a clear airway in 68% of patients with the Williams Airway Intubator compared to only 25% with the Ovassapian Fibreoptic Intubating Airway. We found a clear airway in 88% of patients at the level of the palate and in 92% of the patients at the level of the larynx with a combined laryngoscopy and breoptic technique. The median bronchoscopy times (from insertion of the brescope to passing through the vocal cords) were 9 s and 12 s with the Williams and Ovassapian airways, respectively [13]. In comparison, median bronchoscopy times in our study were 4 s and 3 s with jaw thrust and laryngoscopy, respectively. Randell et al. [14] compared the Ovassapian intubating airway and the Berman intubating airway in a crossover study of 65 patients. With the Berman airway, intubation was prolonged for more than 30 s in 13 patients and failed in three patients, whereas with the Ovassapian intubating airway it was prolonged for more than 30 s in six patients and failed in one patient. This perhaps suggests that the combined laryngoscopy and breoptic technique may offer a better rate of airway clearance than the airways used to aid breoptic intubation. A study by Jackson et al. [15] reported a median bronchoscopy time (from insertion to viewing the carina) of 21 s with a Berman airway, using a paediatric tracheal tube placed between the adult tube and the brescope to reduce impingement of the tube during breoptic orotracheal intubation. The intubation time in this study was dened as that from seeing the carina until recommencement of ventilation, as conrmed by capnography, whereas in our study, intubation time was recorded from the moment the brescope passed through the vocal cords until conrmation of ventilation by capnography. Jackson et al. [15] reported a median intubation time of 31 s with the double setup compared to 18 s in our combined breoptic and laryngoscopy technique; however, direct comparison is difcult because of the differences in study methods.
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M. R. Stacey et al. Direct laryngoscopy vs jaw thrust Anaesthesia, 2005, 60, pages 445448 . ....................................................................................................................................................................................................................

Our study demonstrates the combined laryngoscopy and breoptic technique to be useful in clearing the airway. Cases have been reported where laryngoscopy has been used along with breoptic laryngoscopy to manage difcult intubation [12, 16, 17]. Farley et al. [16] reported a successful left molar direct laryngoscopy approach when conventional laryngoscopy failed to aid breoptic intubation in an unexpectedly difcult intubation. Another report features the use of a McCoy laryngoscopy to aid breoptic intubation [17]. Dennehy & Dupuis [18] also reported the successful use of the combined laryngoscopy and breoptic technique in an unexpected difcult airway. The Difcult Airway Society has recently published guidelines for management of the unanticipated difcult intubation [19]. When an initial tracheal intubation has failed, a secondary tracheal intubation plan (plan B) is attempted using a laryngeal mask airway or an intubating laryngeal mask airway. The technique of combined direct laryngoscopy and breoptic intubation can be used as an alternative to plan B. Familiarity with laryngoscopy makes the combination of laryngoscopy and breoptic intubation a practical technique. We found no difculty in railroading the tracheal tube over the brescope. Indeed, in a recent review, Asai & Shingu [20] suggested that the presence of a laryngoscope can facilitate the passage of the tube over the brescope. This is a potential added advantage of the combined technique. For the purpose of consistency the same experienced endoscopist performed all the intubations. It is possible that a trainee with limited experience in breoptic intubation may be more successful with the combined breoptic and laryngoscopy technique since the tongue, palate and possibly the epiglottis are bypassed when a laryngoscope is used. This technique may facilitate learning breoptic intubation and may possibly shorten the learning curve. Laryngoscopy is a familiar core skill in anaesthetic practice. The technique of combining laryngoscopy and breoptic intubation can readily be used for teaching the management of difcult intubation.
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