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| ORIGINAL ARTICLE |
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| Year : 2023 | Volume
: 2
| Issue : 1 | Page : 32-36 |
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Comparison of intubating conditions and complications of nasotracheal intubation using Macintosh laryngoscope with or without bougie: A randomized controlled trial
Ritu Singh, Babita Ramdev, Sahil Garg, Hersimran Kaur
Department of Anaesthesia and Intensive Care, Maharishi Markandeshwar Institute of Medical Sciences and Research, Ambala, Haryana, India
| Date of Submission | 23-Mar-2023 |
| Date of Decision | 17-Apr-2023 |
| Date of Acceptance | 04-May-2023 |
| Date of Web Publication | 25-May-2023 |
Correspondence Address:
Dr. Sahil Garg
Department of Anaesthesia and Intensive Care, Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana, Ambala - 133 207, Haryana
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jica.jica_6_23
Background and Aim: The purpose of this study was to compare the efficiency of nasotracheal intubation (NTI) using a Macintosh laryngoscope with bougie to a Macintosh laryngoscope without bougie on-time of intubation, the incidence of postintubation bleeding, hemodynamic stress response, and postoperative complications. Materials and Methods: The present randomized blind research was carried out on 120 patients undergoing elective surgeries under general anesthesia. The study population was separated into two groups, each with 60 patients. NTI was performed with bougie using a Macintosh laryngoscope in Group 1 (n = 60) and without the use of a bougie in Group 2 (n = 60) using a Macintosh laryngoscope. Results: In Group 1, 47 (78.33%) patients were successfully intubated in the first attempt, and 13 (21.67%) patients were successfully intubated in the second attempt, whereas in Group 2, 38 (63.33%) patients were intubated in the first attempt and 22 (36.67%) patients required second attempt, with a statistically significant difference. In Group 1, the mean time required for intubation was 31.10 ± 2.36 s, and in Group 2, it took 43.08 ± 2.17 s, P value was statistically significant. In Group 1, the number of patients with a sore throat was 5 (8.33%), with dental injury was 4 (6.67%), and with nasal mucosa laceration was 3 (5%). In Group 2, the number of patients with sore throat was 6 (10%), with dental injury was 6 (10%), and with nasal mucosa, laceration were 5 (8.33%). The difference was not significant in both the groups. Hemodynamic variables were comparable among the groups. Conclusion: Bougie-guided NTI resulted in more successful intubation in terms of less number of attempts, less time taken for intubation, and less postintubation bleeding as compared to NTI without bougie.
Keywords: Bougie, Macintosh laryngoscope, nasotracheal intubation, postintubation bleeding
How to cite this article:
Singh R, Ramdev B, Garg S, Kaur H. Comparison of intubating conditions and complications of nasotracheal intubation using Macintosh laryngoscope with or without bougie: A randomized controlled trial. J Ind Coll Anesth 2023;2:32-6 |
How to cite this URL:
Singh R, Ramdev B, Garg S, Kaur H. Comparison of intubating conditions and complications of nasotracheal intubation using Macintosh laryngoscope with or without bougie: A randomized controlled trial. J Ind Coll Anesth [serial online] 2023 [cited 2023 Jun 8];2:32-6. Available from: https://www.jicajournal.in//text.asp?2023/2/1/32/377603 |
| Introduction | |  |
Nasotracheal intubation (NTI) is inserting an endotracheal tube through the nare into the nasopharynx and trachea, usually following general anesthetic induction in the operating room. Under anesthesia and in intensive care, NTI is a viable alternative to orotracheal intubation, with the added benefit of improved mobility and surgical field. NTI is used for head and neck surgery, oral surgery, or to keep the airway safe while preventing further injury.[1],[2],[3] Postoperatively, the tube is better tolerated by the patients. It is also favored by surgeons doing surgeries in the head and neck region, particularly oropharyngeal, dental, and maxillofacial surgeries since it improves vision and surgical access.[3],[4],[5] With recent advances in techniques and methods, potential problems or complications arising from the blind introduction of the endotracheal tube into the nasal cavity can be avoided.[6],[7],[8],[9]
Conventionally, regular NTI entails the blind insertion of an endotracheal tube via the nares in anaesthetized (i.e., postinduction) patients, followed by passing through the glottis with or without Magill forceps using a laryngoscope (conventional technique). An estimated 54% of people have epistaxis[10] with the use of conventional techniques because of the high vascularity of the nasal mucosa. Chances of trauma are reduced by warming the tube,[11],[12] pretreating the nasopharynx with a topical vasoconstrictor, and using a catheter to guide the tube into the pharynx.[13] NTI is still linked with a significant risk of nasal trauma and tracheal tube cuff rupture, even with the use of nasal vasoconstrictors, tracheal tube warming, and catheter guidance.[6]
Bougie can also be used for guiding the ETT into the trachea. Bougie is a long, stiff plastic wand, which is a simple, inexpensive device, first described by Macintosh in 1949[14] to facilitate orotracheal intubation.
In many randomized trials, the routine use of bougies on every DL intubation led to a higher rate of first-pass intubation success and the bougie technique required less total time to intubate the patient by reducing the time spent guiding the ET tube into the airway.[15]
Furthermore, there are reports of the detachment of the tip of the bougie during intubation due to parching and subsequent weakness of the material with repeated usage.[16] There are traumatic complications of bleeding in airway and esophageal laceration with the use of bougie.[17]
Thus, the primary aim of this study was to compare the number of attempts, intubation time, postintubation hemorrhage, and hemodynamic response during NTI with and without the use of a bougie using Macintosh laryngoscope. The secondary aim was to assess postoperative complications of NTI with and without bougie using Macintosh laryngoscope.
| Materials and Methods | | |
After receiving approval from the Institutional Ethics Committee, this randomized study was done over a period of 2 years in our institute. This study enrolled a total of 120 patients of 18–65 years of age of either gender with ASA Grades I and II scheduled for elective dental and ear, nose, and throat surgeries under general anesthesia with controlled ventilation. While patients are not ready to give consent for the study, ASA grade more than II, Body mass index ≥30 kg/m3 with hypertension, diabetes mellitus or ischemic heart disease, history of epistaxis, nasal polyp, and pregnant patients were excluded from the study.
The patients were allocated to two groups, with sixty patients in each group by random number chart as shown in [Figure 1]. The random number was enclosed in a sealed opaque envelope and opened by the intubating anesthesiologist to know the procedure to be administered. Both patient and the observer anesthesiologist who collected the postoperative data were blinded to the procedure. In Group 1, NTI was performed with bougie using Macintosh laryngoscope, while in Group 2, NTI was performed without bougie using Macintosh laryngoscope.
Preanesthetic evaluation was performed on the day before surgery. Written informed consent was taken a day before surgery. They were given a tablet alprazolam 0.25 mg and tablet pantoprazole 40 mg per orally the night before surgery and again at 6 a. m. with a sip of water on the day of the procedure. Electrocardiogram, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure and peripheral oxygen saturation were recorded in the preoperative room. After confirming nil per oral status, the patient was shifted to operation theater. An intravenous (IV) line was established with an 18G cannula and ringer lactate (500 mL) was started. The patient was induced with injection nalbuphine 0.1 mg/kg, injection propofol (2.5 mg/kg IV) and inj. Vecuronium (0.08–0.1 mg/kg IV) after 3 min of preoxygenation with 100% O2. The patient was intubated with cuffed endotracheal tube using a Macintosh laryngoscope with or without bougie as per group allocation. In Group I, nasopharyngeal airway was inserted through the more powerful nostril. Bougie was inserted into the nasopharyngeal airway, tip pointing forward and was advanced distally in the trachea until it met resistance. Over the bougie, the nasopharyngeal airway was eliminated. Then, the tracheal tube was inserted over the bougie using the Seldinger technique. Then bougie and laryngoscope were removed, and bilateral chest auscultation and capnography were used to confirm the nasotracheal tube insertion. If intubation has not been successful after two attempts with bougie, then the conventional technique was used. In Group 2, NTI was done without using bougie. Under Macintosh laryngoscope vision, the tube was pushed through the pharynx and past the vocal cords using external manipulation. With or without the use of Magill forceps, the tracheal tube was advanced until it was visible, passing through the vocal chords. The blade was progressively withdrawn and bilateral chest auscultation and capnography were used to confirm nasotracheal tube position. Now, the anesthesia was maintained with O2, N2O, isoflurane, and injection vecuronium. After completion of surgery, patients were reversed with injection myopyrolate 5 mL at the end of the procedure.
The outcomes noted during induction of anesthesia were the number of intubation attempts in each group, time to intubate in seconds, postintubation bleeding evaluated by subjective bleeding scale (0-No bleeding, 1-Minimal bleeding not requiring suctioning, 2-Moderate bleeding, which will require suctioning without hampering visualization, 3-severe bleeding which will require suctioning and hampers visualization).
Hemodynamic parameters such as SBP, DBP, heart rate (HR), and SpO2 were noted at T0 (baseline), T1 (immediately after induction), T2 (at the time of intubation), T3 (1 min after intubation), and T4 (5 min after intubation). Postoperative complications, including sore throat, dental injury, and nasal mucosa laceration, were also recorded.
Statistical analysis
The data collected were analyzed using Statistical Package for social sciences (SPSS version 20, IBM, Chicago, Illinois, USA). Continuous variables were analyzed using an unpaired t-test. Categorical variables were analyzed using Chi-square test. P < 0.05 was considered significant at a 95% confidence interval. P > 0.05 was not statistically significant.
Sample size calculation
A post hoc power analysis was conducted using the software package, G * Power (Faul and Erdfelder) (1992), the alpha level used for this analysis was P < 0.05 and the beta was 0.20. The sample size was estimated from the results of the previous study using the incidence of nasal bleeding at 90 s as the parameter, which is the primary outcome of our study. The sample size came out to be 60 subjects per group at a power of 0.81 and with an effect size of 0.26 with 10% chance of error with α = 0.05, β = 0.20, and confidence interval of 95%.
| Observation and Results | | |
Demographic characteristics of both the groups were comparable and results were statistically insignificant (P > 0.05). In Group 1, 78.33% (n = 47) patients were successfully intubated in the first attempt, whereas 13 (21.67%) patients required a second attempt. In Group 2, 63.33% (n = 38) patients were intubated in the first attempt and 22 (36.67%) patients required the second attempt. The difference between both the groups was statistically significant [P < 0.05, [Table 1]]. In Group 1, the mean time required to intubate a patient was 31.10 ± 2.36 s and in Group 2, the mean time required to intubate a patient was 43.08 ± 2.17 s. The difference between both the groups was statistically significant [P < 0.05, [Table 2]]. The incidence of postintubation bleeding was more in Group 2 as compared to Group 1 and the difference was statistically significant [P < 0.05, [Table 3]]. The difference of SBP between both the groups was statistically not significant at all time intervals (P > 0.05). Similarly, the difference of DBP between both the groups was statistically not significant at all time intervals (P > 0.05). The difference of HR between both the groups was statistically not significant at all time intervals (P > 0.05). The difference in arterial oxygen saturation between both the groups was statistically not significant at all time intervals (P > 0.05). Postoperative complications between both the groups were comparable and statistically insignificant [P > 0.05, [Table 4]]. | Table 2: Comparison of time of intubation (s) between Group 1 and Group 2
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 | Table 3: Comparison of postintubation bleeding between Group 1 and Group 2
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 | Table 4: Comparison of postoperative complications between Group 1 and Group 2
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| Discussion | | |
The demographic profile such as age, gender, weight, and ASA status were comparable in both the groups in our study and was in accordance with the study done by Abrons et al.,[18] Pourfakhr et al.[19] and Driver et al.[15] The number of patients intubated in first attempt was more in Group 1 as compared to Group 2 which was statistically significant (P = 0.041), showing that NTI done with bougie was easier and successful in the first attempt in comparison with intubation without bougie. Thus, the current study was in accordance with the study done by Driver et al.[15] and Arisaka et al.[20] The mean time required for NTI in Group 1 was less as compared to the group and was statistically significant (P < 0.01), showing that NTI done with bougie required less time when compared with intubation without bougie. The current study was in accordance with the study done by Pourfakhr et al.[19] and Cossham[21] NTI done with bougie had less postintubation bleeding when compared with intubation without bougie in our study. The current study was in accordance with the study done by Morimoto et al.,[10] Abrons et al.[18] and Vadhanan et al.[22] In our study, there was no significant difference found between SBP, DBP, HR, and SpO2 at various time intervals in Group 1 and Group 2. Thus, both the groups were comparable in above parameters (P > 0.05). The results were found to be similar to the study done by Arisaka et al.[20] and Pourfakhr et al.[19] In our study, postoperative complications between both the groups were comparable (P > 0.05). Thus, the current study is in accordance with the study done by Driver et al.[15] Nolan and Wilson.[23]
Limitations of study
- The anesthetists were not blinded to the intervention was a key limitation in this trial. To avoid performance bias, the intubating anesthetist was informed of the group assignment after anesthesia had been induced
- Nasal bleeding is multifactorial and nasal cavity anatomy was not controlled for.
| Conclusion | | |
Bougie-guided NTI resulted in more successful intubation in terms of less number of attempts, less time taken for intubation, and less postintubation bleeding as compared to NTI without bougie. Hence, we recommend the use of bougie in NTIs.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4]
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