الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
The anatomic etiological features thought to be associated with difficulty in airway management are; anterior larynx, poor neck mobility, small mouth opening, short neck, less than 6 cm thyromental distance, large tongue and protruding teeth.
For managing patients in whom a difficult airway is suspected or anticipated; awake technique of intubation is chosen for securing the airway before induction of general anesthesia. This adds safety of anaesthesia and helps minimize the possibility of major complications.
Over the past two decades, a large number of airway devices have been introduced into clinical practice as adjuncts to management of the difficult airway. The lightwand transillumination technique is an effective and safe intubating technique, in which no direct-vision laryngoscopy is required. The early lightwands were insufficient for clinical use because of the inadequate light bulb for transillumination, loose light bulb connection to the wand, and rigidity of the wand. Recently, a new lightwand (TrachlightTM; Laerdal Medical, Armor, NY) has been developed. It has a brighter, non-removable bulb and a flexible wand. The TrachlightTM makes tracheal intubation easier than laryngoscopy.
Other new devices have been developed to assist anaesthesiologists with both routine and difficult airway management, one of which is the Bonfils Retromolar Intubation Fiberscope™. It is useful in patients with limited neck mobility, patients with cervical spine injuries, and for endoscopic guidance during percutaneous tracheostomies.
Flexible fiberoptic intubation is a very reliable approach to difficult airway management and assessment. It has a more universal application than any other technique. It can be used orally or nasally for both upper and lower airway problems and when access to the airway is limited, as well as in patients of any age and in any position. The motion of the tip of the fiberscope can be controlled which enables the operator to direct the scope in any desired fashion. The combined characteristics of controllability, flexibility and image transmission permit anaesthesiologists to employ the fiberscope as an aid to difficult tracheal intubation and as a therapeutic instrument.
This work aims at assessing the efficacy of Trachlight, Bonfils fiberscope and flexible intubating fiberscope in the management of patients with anticipated difficult airway. The efficacy is assessed as regards easiness of the technique and hemodynamic response.
After the approval of ethical committee of the Faculty of Medicine and taking informed written consents from the patients; the present study was conducted on 36 patients of both sexes suffering from limited mouth opening or limited neck mobility admitted to Alexandria Main University Hospital, and scheduled for elective surgery. The patients were divided into three equal groups according to the technique of intubation used. Group I was intubated using Trachlight, group II was intubated using Bonfils fiberscope and group III was intubated using flexible intubating fiberscope.
Patients were divided randomly (random no. table) equally among the groups (12 patients each) according to the technique of intubation. Group I: Using Trachlight. Group II: Using Bonfils fiberscope. Group III: Using Flexible Intubating fiberscope.
The results of the present study revealed that there was no statistically significant difference between the three groups in sex distribution or in the mean age and nor in the ASA classification. There were also no statistical significant differences between the three studied groups regarding weight, height and BMI.
As regards the airway assessment there were no significant statistical differences between the studied groups in previous difficult intubation, Mallampati test, atlanto-occipital joint angle, mouth opening, thyromental distance, sternomental distance.
The most common cause for airway difficulty in the present study was ankylosing of mandible, others were; cervical ankylosing spondylitis, malunited fracture of mandible, cervical spine tumour and finally skin burn scar of the neck which was one case in group II.
Regarding the intubation criteria, there was only one trial done in groups II and III. In group I; two cases experienced 2 trials during the intubation procedure. There were no statistical significant differences between the three studied groups. Duration of attempts ranged between 25.0-55.0, 20.0-60.0 and 37.0-58.0 seconds for groups I, II and III respectively, group III have values statistically higher than group II. Total duration ranged between 25.0-98.0, 20.0-60.0 and 37.0-58.0 for groups I, II and III respectively, group III have values statistically higher than group II. As for degree of difficulty for intubation, “easy were found in 16.7%, 16.7% and 8.3%, neutral degree were found in 25.0%, 50.0% and 50.0%, difficult degree were found in 50.0%, 33.3% and 41.7%, very difficult degree were found in 8.3%, 0.0% and 0.0% for groups I, II and III respectively, with no statistical significant differences.
There were 2 cases in the Trachlight group with failed intubation as a 1st trial but were managed with intubation in the 2nd trial with the same device. Failure to intubate was considered after 60 seconds from starting of the procedure.
As regards the hemodynamics and stress response; in group I (Trachlight) the mean pulse rate and systolic blood pressures showed significant increase after intubation, while there was no significant change after 15 min of intubation. On the other hand there were no significant changes for mean diastolic pressure. As for the mean arterial pressure there were significant change in after intubation and 15 min after intubation. In the current study; adrenaline, noradrenaline and cortisol levels after 15 min showed significant increase in comparison to before intubation. The Trachlight technique is a blind one in which the endotracheal tube may touch the tongue base, vallecula, epiglottis or the piriform fossa during the introduction trials. That may be an added cause to the chin lift done to increase the hemodynamic response.
In group II (Bonfils fiberscope) the mean pulse rate and systolic blood pressures showed significant increase after intubation, while there was no significant change after 15 min of intubation. On the other hand there were no significant changes for mean diastolic pressure. As for the mean arterial pressures, it showed there is significant change in after intubation but not in 15 min after intubation. In the present study adrenaline, noradrenaline and cortisol levels after 15 min showed significant increase in comparison to before intubation. The introduction of the retromolar fiberscope into the oropharynx is under vision, which gives us the opportunity to direct the endotracheal tube into the larynx with minimal or no contact with the epiglottis.
In group III (Flexible intubating fiberscope) the mean pulse rate showed significant increase after intubation and 15 min after intubation. On the other hand there were significant changes for mean systolic and diastolic pressures only after intubation with no significant difference after 15 min of intubation. As for the mean arterial pressures, it showed there is significant change in after intubation but not in 15 min after intubation. In the current study; adrenaline, noradrenaline and cortisol levels after 15 min showed significant increase in comparison to before intubation.
In the current study there were significant differences between the preoperative mean oxygen saturation in comparison to before intubation, after intubation and 15 min after intubation periods in the three studied groups. This can be attributed to the oxygen supplementation via the applied nasal cannula. There were no statistically significant differences between the mean oxygen saturations between before intubation, after intubation and 15 min after intubation.
In this study there were only two cases complicated by minimal mucosal bleeding in the Trachlight group during intubation.
In conclusion, intubation with a flexible intubating fiberscope requires the longest time, causing the greatest stress response to patients. Intubation with Bonfils fiberscope is faster in comparison to Trachlight, and to a fibreoptic bronchoscope, at the same time causing the lesser stress response to patients. The Trachlight is a reliable airway device for patient safety; it’s cheaper, more portable and could be used when there are secretions or blood present.