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A RANDOMIZED CONTROL TRIAL COMPARING THE

KING VISION VIDEO LARYNGOSCOPE AND THE D BLADE

OF THE CMAC VIDEO LARYNGOSCOPE IN PATIENTS

WITH C SPINE IMMOBILIZATION

A dissertation submitted to the Tamil Nadu Dr. M. G. R. Medical University, Chennai

in partial fulfillment of the requirement for the MD Anaesthesiology (Branch X)

degree examination to be held in April 2017.

 

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A RANDOMIZED CONTROL TRIAL COMPARING THE

KING VISION VIDEO LARYNGOSCOPE AND THE D BLADE

OF THE CMAC VIDEO LARYNGOSCOPE IN PATIENTS

WITH C SPINE IMMOBILIZATION

Dissertation submitted to the

THE TAMIL NADU DR. MGR MEDICAL UNIVERSITY, CHENNAI

In partial fulfillment of the requirements for the degree of

MASTER OF MEDICINE

IN

ANAESTHESIOLOGY

By

JACOB CHANDY

Register number: 201520355

DEPARTMENT OF ANAESTHESIOLOGY

CHRISTIAN MEDICAL COLLEGE

VELLORE

APRIL 2017

 

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CERTIFICATE

This is to certify that “A RANDOMIZED CONTROL TRIAL COMPARING

THE KING VISION VIDEO LARYNGOSCOPE AND THE D BLADE OF

THE CMAC VIDEO LARYNGOSCOPE IN PATIENTS WITH C SPINE

IMMOBILIZATION” is the bonafide work of Dr. Jacob Chandy under my

supervision in the Department of Anaesthesiology, Christian Medical College Vellore

in partial fulfillment of the requirements for the M.D Anaesthesiology Examination

Branch X of the Tamil Nadu Dr. M.G.R Medial University to be held in April 2017

and no part thereof has been submitted for any other degree.

Dr. Sajan Philip George

Professor, Department of Anaesthesiology

Christian Medical College,

Vellore

 

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CERTIFICATE BY THE HEAD OF THE DEPARTMENT& PRINCIPAL This to certify that This is to certify that “A RANDOMIZED CONTROL

TRIAL COMPARING THE KING VISION VIDEO LARYNGOSCOPE

AND THE D BLADE OF THE CMAC VIDEO LARYNGOSCOPE IN

PATIENTS WITH C SPINE IMMOBILIZATION” is the bonafide work of

Dr. Jacob Chandy under the supervision of Dr.Sajan Philip George, Professor of

Anaesthesiology in the Department of Anaesthesia, Christian Medical College

Vellore.

Dr. Sajan Philip George Dr Anna P Pulimood

Professor and Head Principal

Department of Anaesthesiology Christian Medical College

Christian Medical College Vellore.

Vellore.

 

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DECLARATION

I, Jacob Chandy, do hereby declare that the dissertation titled “A RANDOMIZED

CONTROL TRIAL COMPARING THE KING VISION VIDEO

LARYNGOSCOPE AND THE D BLADE OF THE CMAC VIDEO

LARYNGOSCOPE IN PATIENTS WITH C SPINE IMMOBILIZATION”

is a genuine record of research done by me under the supervision and guidance of Dr.

Sajan Philip George, Professor, Department of Anaesthesiology, Christian Medical

College, Vellore and has not previously formed the basis of award of any degree,

diploma, fellowship or other similar title of any university or institution.

Vellore Dr. Jacob Chandy

Date : September 25th 2016

 

 

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ACKNOWLEDGEMENT

I acknowledge my dependence and gratitude to God in the successful completion of this thesis.

I express my sincere and heartfelt gratitude to Dr. Sajan Philip George, HOD and Professor, Department of Anaesthesiology, Christian Medical College, Vellore for his encouragement, meticulous support and marvelous guidance during the study.

I express my sincere and heartfelt gratitude to Dr. Melvin Alex, Assistant Professor, Department of Anesthesiology, Christian Medical College, Vellore, for his tremendous support and excellent assistance throughout the study.

I acknowledge my sincere gratitude to Dr. Raj Sahajanandan, Professor, Department of Anaesthesiology, Christian Medical College, Vellore, for his valuable advice and guidance for the conduct of this study.

I express my sincere thanks to Mr. Bijesh Yadav, Department of biostatistics, Christian medical college, Vellore for helping us through the study design and statistical analysis of this study.

I thank all my colleagues and anaesthesia technicians for their sincere and overwhelming support at all stages of this study.

I thank my family for their constant support and encouragement during this study.

I thank all the patients who consented to be part of this study without whom it would have been impossible to have this done.

 

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Table of Contents

Sl. no. Contents Page No

1 Introduction 12

2 Aims and Objectives 15

3 Review of Literature 17

4 Methodology 46

5 Results 54

6 Discussion 81

7 Conclusion 88

8 Limitation 90

9 Reference 92

10 Appendix 97

 

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Introduction

 

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Introduction:

In patients with cervical spine injury, manipulation of the neck during endotracheal

intubation can lead to permanent spinal cord damage(1)(2). Manual inline stabilization

(MILS) is a method to minimize neck movement during intubation. Such

immobilization can render direct laryngoscopy and tracheal intubation difficult(3).

Video laryngoscopes provide better visualization of the glottis without a straight line

view as compared to the Macintosh blade(4). Therefore video laryngoscopes are more

useful in patients with cervical spine pathology in whom neck movement must be

avoided during tracheal intubation(5).

The CMAC is a non channeled video laryngoscope. The D blade of the CMAC system

was developed by Dr Volker Dorges. The primary distinguishing feature of the D

blade is its shape, which is an elliptically tapered blade rising to the distal. It claims to

provide an easy option in difficult laryngoscopies (Cormack and Lehane grade 3 and

4)(6). Complications like swelling, haemorrhage and other side effects of a difficult

intubation can be avoided.

King Vision video laryngoscope is another type of video laryngoscope with OLED

display and designed to provide minimal lifting of soft tissue and claims to minimize

trauma during endotracheal intubation(7). A channeled blade provides a port for easy

introduction of the endotracheal tube.

 

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These two video laryngoscopes will be used in patients with a normal airway whose

C-spines have been immobilized by MILS to mimic an unstable cervical spine. It is

hypothesized that the King vision video laryngoscope being a channeled scope, will

reduce the time to successful intubation and thereby reduce the haemodynamic

response to intubation and associated complications such as trauma(8).

 

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Aims and Objectives

 

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Aims and Objectives:

1) Time for visualization of the glottis and time for successful intubation in patients

with cervical spine immobilization using the study video laryngoscope.

2) Subjective grading of the ease of intubation with the video laryngoscope using the

intubation difficulty scale (IDS), haemodyamic monitoring and associated

complications.

 

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Review of literature:

                                 

 

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Review of literature:  Spinal cord injury is a fatal consequence of cervical spine injury from either disease or

more commonly, trauma. Of all the blunt trauma patients, cervical spine injury affects

2-5%(9) and the risk increases in patients with facial or head injury, decreased

consciousness or those with focal neurological deficits (1)(10).

Patients with a possible cervical spine injury, in the setting of trauma, would require

urgent airway intervention for various reasons such as protection of the airway,

hypoxia, hypoventilation or hypotension. Patients with known cervical spine injury or

disease may be encountered in the elective setting for either cervical spine surgery or

any other elective surgery.

Cervical spine anatomy:

The cervical spine comprises of seven vertebrae and their corresponding ligaments

and intervertebral discs [Figure 1]. The 2 upper most cervical vertebrae, the atlas and

axis (C1) (C2) respectively, support the mobility and weight of the skull (occiput).

They respectively form the atlanto-occipital and atlanto-axial joints. The cervical

spine has ligaments, which are divided into 2 columns.

The posterior column provides sturdiness during flexion and incorporates the

supraspinous ligament, interspinous ligament, and ligamentum flavum. The anterior

column furnishes sturdiness during extension and comprises of the longitudinal

ligament (posterior), the longitudinal ligament (anterior), and three ligaments that

fasten the dens (odontoid process) of C2 to the arch of the anterior part of C1. These

include the apical ligament, the occipital and the atlantal portions of the alar ligament,

 

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and the transverse ligament.

These 3 ligaments restrict the translational movement between the atlas arch and the

dens to less than three millimeters. If there is damage to the transverse ligament, then

translation approaches five millimeters and if all 3 are damaged, in cases of trauma or

rheumatoid arthritis, then translation has been approximated to up to ten

millimeters(11).

Figure 1: Cervical Spine Anatomy. (a) Lateral view of the 7 cervical vertebra, pedicles

and laminae are discarded to show the spinal cord space (gray), (b) Ligaments

creating the anterior and posterior columns shown in the lateral cross section, ALL-

Anterior longitudinal ligament, PLL- Posterior longitudinal ligament, LF-

Ligamentum flavum, ISL- Interspinous ligament, SSL-Supraspinous ligament, (c)

Superior perspective of the first on second cervical vertebra and transverse ligament

(TL), which usually restricts the translation and the atlas-dens interval (ADI)

 

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Cervical spine mechanics:

Usually the ligaments and bones of the cervical spine work to guard the spinal cord

from injury. The interpretation of a stable spine is, the capability of the spine to reduce

the amount of displacement under physiologic stress so as to not permit destruction or

irritation to the nerve roots or spinal cord(12). If the canal of the spinal cord becomes

narrow, spinal cord damage occurs and if this continues, then spinal cord injury

results.

At the region of C1, if the spinal canal is viewed in a sagittal plane, the anterior 1/3rd

is occupied by the dens, the middle 1/3rd is spinal cord, and the posterior 1/3rd is the

space provided for the spinal cord. This space demonstrates a buffer to guard the

spinal cord in case narrowing of the spinal canal occurs from instability of the

vertebra, subluxation of the vertebra, impingement of the disc or swelling of the spinal

cord. The canal of the spinal cord and the space provided for the spinal cord are

spaces, which are dynamic. It has a fixed volume with certain mechanisms that are

impacted by the Poisson Effect(13).

This idea imposes that if a fixed volume of a column is compressed, its CS (cross-

section) area would increase. On the other hand, if it gets stretched, its CS area would

decrease. Demonstrating the body of vertebrae as the axis during extension and

flexion, the Poisson Effect can be applied to the spinal column [Figure 2].

 

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Figure 2: The Poisson Effect given to the Cervical Spine (a) During flexion of the

neck, the cervical spine axis is the body of the vertebrae, so both spinal cord and the

space provided for the cord are lengthened and tapered (gray hatch marks), (b) During

extension of the neck, both the cord of the spine and the space provided for the cord

are flattened and also widened.

During flexion of the neck, the cord of the spine and the spinal canal are stretched and

this can lead to even more reduction of the space provided for the cord by

impingement of the posterior part of the damaged intervertebral disc, or the vertebral

body, which gets subluxed. On the contrary, during extension of the neck, the length

 

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of the cord and canal of the spine is reduced, which increases the CS area of each.

Initially it would appear that extending the neck and increasing the space provided for

the spinal cord would be better for the patient, but the opposite has been proven to be

true(14).

The bulge of the Ligamentum flavum, caused by laxity resulting from the decreased

height of the vertebral body has been speculated for the possible reason for extension

injury. This disadvantageous ratio of the spinal cord to the space present for the cord

is likely to be elucidated by the fact that the spinal cord is a column of almost fixed

volume and is controlled by the Poisson Effect.

As both limits of movement can be suspected in reducing the available space for the

spinal cord, it should be realized that increased flexion or extension during

management of the airway and positioning during surgery, prone position in

particular, which causes extremes of extension, can lead to compromise or more

fatally damage to the spinal cord. For this, “neutral positioning” is what is advised.

Unfortunately, there is no global definition describing neutral positioning.

Cervical spine injury types:

Health care providers treating trauma patients should be taught to have basic

knowledge of the types of cervical spine injuries and the mechanisms involved. Types

of injury are hyperextension, hyperflexion, compression, and clinically insignificant

 

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injuries.

[Figure 3]

Figure 3: Cervical Spine Injury (a) Hyperflexion causing a vertebral body wedge

fracture, (b) Hyperextension causing “Jefferson” fracture of the C1 arches anteriorly

and posteriorly, (c) Hyperextension casing “Hangman’s” fracture of the pedicles of

C2, (d) Compression injuries causing vertebral body burst fractures and retropulsed

bone fragments

 

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Cervical spine movement during intubation:

With the increased proximity of the structures of the airway to the cervical spine, it

has been concluded that airway intervention and positioning can cause significant

displacement of the spinal cord and the space. The sniffing position, which is used

during intubation of the trachea, involves almost full extension of the joints at the

atlanto-occiput and the atlanto-axis and flexion of the joints of the lower cervical

spine.

Every injury of the cervical spine is unique, and there is no universal standard of

measurement. Both static X-rays and dynamic fluoroscopy have been used for

measurement. But there is disagreement as to if the main focus should be on motion of

segments of 2 or 3 vertebrae versus cervical spine motion in total. These questions

have been very ambiguous, because it would be ethically incorrect to subject potential

cervical spine injury patients to a study, which is double-blinded and placebo

controlled.

One study by Hauswald et al., which used cinefluoroscopy to calculate the mean

maximum displacement of the cervical spine during manipulation of the airway in

eight human victims who had traumatic arrests within forty minutes of death showed

that mask ventilation resulted in the most displacement (2.93 millimeters), followed

by endotracheal intubation over a stylet (1.65 millimeters), oral endotracheal

intubation (1.51 millimeters), whereas, intubation through the nose resulted in least

displacement (1.20 millimeters)(15).

When Sawin et al. did a study which measured the displacement of the cervical spine

 

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during endotracheal intubation in ten non trauma patients, they concluded that

insertion of the laryngoscope caused reduced movement while elevation of the blade

resulted in significant extension at every motion segment, more commonly at the

atlanto-occipital and the atlanto-axial joints, whereas endotracheal intubation resulted

in a very small degree of additional rotation(16).

Robitaille et al. used cinefluroscopy to study cervical spine movement during

intubation with direct laryngoscopy and compared it with intubation using the

Glidescope video laryngoscope when manual in line stabilization was applied to both

sets of patients respectively. They found no significant difference between the two

though glottis visualization was better with the Glidescope video laryngoscope(17).

Risk stratification for cervical spine injury:

Demetriades et al. found a relation between the Glasgow Coma Scale (GCS) and

injury to the cervical spine(1).The incidence of spinal cord injury in patients with a

GCS of 13-15 was only 1.4% whereas those patients with a GCS of 9-12 had spinal

cord injury of 6.8% and GCS ≤ 8 had 10.2%. Hackl et al. calculated odds ratios (OR)

of cervical spine injury in the presence of other clinical findings and revealed that

there is an association between severe head injury and cervical spine injury (OR 8.5),

those patients with prolonged unconsciousness (OR 14), and those with focal

neurologic deficit, (OR 58)(10). While it is important to identify patients who are at

high risk, the gold standard of care for these patients is cervical immobilization until

any injury to the cervical spine is ruled out.

 

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Neck immobilization:

The neck should be immobilized in a position that is natural and neutral with the use

of manual inline stabilization (MILS), collars, hardboard with sandbags and traction

pins. Non-traumatic spinal cord diseases include ankylosing spondylitis, which require

increased padding under the head to give the patient the natural position.

Health care providers should be perfect with the various methods available for

cervical spine immobilization and the various implications involved in management of

the airway. Gold standard for immobilization of the neck is the combined use of a

hard board, a collar, sandbags, and tape or straps. This is primarily used in transfers

from the field to the hospital and can reduce the movement to approximately 5% of

range normally seen. The problem with this kind of immobilization is that it carries an

increased risk of injury by pressure and reduces the laryngoscopy view attained.

A study performed by Heath et al., found that majority of the people (64%), had

Grade three or four views with laryngoscopy when immobilized with collar-

hardboard-tape-sand bag kind of combination(18).

 

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Figure 4 Neck Maneuvers During Airway Management. (a) Neck stabilization with

sandbag-collar-tape on hardboard for field care, (b) Cricoid pressure applied where

anterior ½ of the hard cervical collar is removed and the other hand rests behind the

cervical collar posteriorly, (c) Manual in-line stabilization (MILS) from the head of

the bed, with the anterior cervical collar removed and hands supporting mastoid

process and occiput, (d) Manual inline stabilization (MILS) from the bedside to allow

intervention of the airway from the head end of the bed .

 

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Semi-rigid collars:

Podolsky et al. describe the hard Philadelphia collars to be better than the soft ones

but probably not as good as the combination provided by the spine board-sandbag-

tape-collar at limiting the movement in volunteers who were told to extend, flex,

rotate, bend the neck laterally while in supine(19). Bednar revealed his findings in a

cadaver model, which comprised of the anterior and posterior column. He found that

the semi-rigid collars did not limit the pathologic displacement and cervical motion

can contrarily be increased, by serving as a lever(20). In spite of these findings, and

the lack of some convenient alternative, semi-rigid collars are used and their valuable

implications for airway management should be taken seriously.

One important consideration about the hard collar is that they greatly decrease the

opening of the mouth. Goutcher calculated the average inter-incisor distance in

various volunteers as a baseline (41 millimeters) and after (26-29 millimeters) the

application of a hard collar. More than twenty percent of the participants had a mouth

opening of <= twenty millimeters (21).

Two recent studies performed on the cadaveric models further highlight the

limitations of the cervical collar placement. In the first study, Prasarn et al., showed

that even the removal and application of the cervical collar can be associated with

displacement of the cervical spine. He suggested that collars should be removed and

placed with MILS (22).

In a second cadaveric study, Horodyski et al. showed that neither one nor two piece

collars were effective in decreasing the segmental movement in the unstable or stable

 

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cervical spine. There was a worse performance in the unstable cervical spine

condition(23). The current literature proves that MILS and great vigilance is required

in managing a patient with potential cervical spine injury. Cervical collar application

is only one part of the management. In addition, the demonstration of limitations of

cervical collar placement shows the need for further research in immobilization

techniques for patients with an injured cervical spine.

Manual in line stabilization:

Manual inline stabilization (MILS) is used frequently in patients with actual or

suspected cervical spine injury to reduce the risk of permanent cord injury during

intubation of the trachea(2). MILS has become the standard of care during securement

of the airway in trauma patients(24).

The main concern is that MILS makes it more difficult to visualize the cords with

conventional laryngoscopy(3)(18).This can lead to failure in intubating the trachea

and securing the airway, a cause of significant morbidity and mortality in the

operative setting(25)(26), and emergency setting(27) in spite of advancements in

airway management.

MILS makes direct laryngoscopy more difficult, because of the difficulty in aligning

the oral, pharyngeal, and laryngeal axes in order to visualize the cords when the neck

is immobilized.

As limitation in opening the mouth affects endotracheal intubation, a frequently used

practice is to remove the anterior half of the collar and have the assistant provide

MILS during intubation of the airway. This can be achieved with the assistant

 

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standing by the head end of the bed or the side of the bed and using their fingers and

palms of both hands to stabilize the patient’s mastoid process and occiput so as to

gently prevent the counteracting forces to cause airway manipulation [Figure 4].

While it is a good way to avoid the problem of decreased mouth opening, MILS is far

from being perfect.

Nolan in his study found that, when compared to the sniffing position, MILS reduced

the laryngoscopic view in 45% of patients. Twenty two percent of patients had a grade

III (epiglottis only) view with MILS. Using a gum-elastic bougie increased the rate of

endotracheal intubations greatly(28). While manual inline stabilization anchors and

protects the occiput and the torso anchors and protects the lower cervical spine, it is

highly possible that forces of laryngoscopy be transferred to the mid-cervical spine.

Airway management for cervical spine injury:

Like many fields of medicine, practice criteria for airway management in patients with

probable cervical spine injury have changed dramatically over the past years. Surgical

crico-thyrotomy was specified by the Advanced Trauma Life Support guidelines in

such patients to reduce cervical spine displacement, but it was not well researched or

done always. In the late 1980s, Holley and Jordan reviewed 133 endotracheal

intubations and found that intubation through the nose was done (71%) much more

often than direct laryngoscopy with MILS (22%)(29).

In the 1990s, Rosenblatt and McCrory found that anesthetists preferred to perform

 

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awake fiberoptic endotracheal intubations (60-78%) over direct laryngoscopy under

general anesthesia (32-40%)(30). Video laryngoscopes such as the Glidescope, not

introduced until around the year 2000, are widely used in combination with manual

inline stabilization or a complete hard cervical collar in order to reduce displacement

of the cervical spine in these patients.

Awake fibreoptic intubation:

Awake fiberoptic intubation is a great option for elective and semi emergent

situations. The patients have to be co-operative in this situation. It allows for

documentation of neurologic status before and after intubation of the patient.

However, the use of this technique requires significant expertise and skill and may be

complicated in situations which are emergent. Such situations include, if a patient is

too anxious to be cooperative, if a provider is not skilled in fiber optic endotracheal

intubations, or if there is blood or other secretions in the airway.

With established skill in fiberoptic laryngoscopy, correct patient selection, and

adequate anesthesia of the structures of the airway, awake fiberoptic intubation has

been shown to be a great option in many studies. In a recent study, Malcharek et al.

showed that in a group of patients at risk of secondary injury to the cervical spine,

fiberoptic intubation and patient self-positioning in the prone position after

endotracheal intubation was highly successful and feasible (31). For the anxious

patient, studies have showed that infusions of Remifentanil or Dexmedotomindine

 

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may allow for a more cooperative patient during the procedure of awake fiberoptic

intubation(32)(33).

Direct laryngoscopy:

Direct laryngoscopy is technically easier to perform than fiberoptic intubation or

video laryngoscopy and, therefore, is excellent in the emergent scenario. As evidenced

by a review of around 32,000 emergency intubations by experienced anesthetists,

direct laryngoscopy was found to be safe and effective(34). When Ong et al.

compared video-laryngoscopy with fiberoptic laryngoscopy and direct laryngoscopy(

Macintosh blade), they found that direct laryngoscopy was quicker in normal airways

and similar to the other scopes in patients with difficult airway(35).

In immobilized patients, especially for emergency intubations, direct laryngoscopy

with the use of a gum elastic bougie is a good choice to convincingly secure the

airway while reducing the force applied to the cervical spine.

Laryngeal mask airway:

Laryngeal mask airways (LMAs) remain controversial for airway management in

patients with known or suspected cervical spine injury, as some studies have shown

increased cervical spine displacement in comparison to intubation and other studies

have shown no significant difference between the two(36)(37).

In addition to providing ventilation in a potentially disastrous cannot intubate, cannot

 

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ventilate situation, LMAs can often be used to facilitate tracheal intubation. A study

by Arslan et al. compared different LMAs placed in patients wearing cervical

collars(38). Their findings suggest that the Airtraq single use LMA may be associated

with shorter intubation time and less damage to the mucosa in patients with an

immobilized cervical spine. The Fastrach LMA system has been validated for use in

difficult airway scenarios which includes cervical spine immobilization(39).

Joffe et al. showed how a gum elastic bougie can be used to help in placement of an

LMA Proseal without the help of an assistant(40).

This may be a valuable strategy in potential cervical spine injury without

oropharyngeal or esophageal trauma.

Regardless of the type of LMA used, they remain an essential tool in the difficult

airway algorithm for patients, including those with trauma and potential cervical spine

injury.

Video laryngoscopy:

Video laryngoscopy is an excellent option because its angulation and indirect

technique requires less force for glottic view and endotracheal tube placement. Its

narrow blade requires lesser mouth opening than most traditional laryngoscopes.

Video laryngoscopes only require alignment of the pharyngeal and laryngeal axes

which lie along much more similar angles when compared to the oral axis. This is

another reason that simplifies endotracheal intubation.

Video laryngoscopes have been introduced to clinical anesthesia to counter the

 

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problem of difficult intubation. The design and optics have evolved during the last

two decades and have become part of the guidelines of the Difficult Airway society

(DAS), for the management of anticipated difficult airway. 2015 modification of DAS

guidelines have indicated to use video laryngoscope as primary airway management

plan in anticipated difficult airway rather than use them as back up plan.

Figure 5:modifications in DAS guidelines where video laryngoscopes are used as the

first option in an anticipated difficult airway scenario to optimize success on the first

attempt (The 2015 DAS guidelines).

Video laryngoscopes can either be a channeled scope or a non channeled scope. The

channeled scopes have a channel where the endotracheal tube is preloaded before

 

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laryngoscopy, whereas the non channeled scopes have no such channel and hence the

endotracheal tube has to be separately introduced along the side of the scope after

glottis visualization. Examples of channeled video laryngoscopes include the Airtraq,

Airway scope and the King vision. Examples of non channeled scopes include the

Glidescope and the CMAC.

A number of studies have been done which compare video laryngoscopes with

conventional laryngoscopes as well as studies which compare channeled and non

channeled video laryngoscopes in patients with cervical spine immobilization.

Bruck et al. compared the CMAC video laryngoscope with the Glidescope in patients

with cervical spine immobilization and concluded that both the video laryngoscopes

provided excellent laryngeal visualization and that the Glidescope provided higher

first attempt success rate for endotracheal intubation.(41)

Acute angulation and less mouth opening explain how the Glidescope, when

compared with direct laryngoscopy, was used to improve laryngoscopic view and help

in successfully intubating patients wearing cervical collars. This study was performed

by Bathory et al(4).

Mcelwain and Laffey compared the CMAC and Airtraq video laryngoscopes to the

conventional Macintosh blade in patients undergoing tracheal intubation with cervical

spine immobilization with the help of manual inline stabilization. They concluded that

the Airtraq video laryngoscope provided better glottis visualization when compared to

the CMAC, which in turn performed better than the conventional scope. Intubation

difficulty scale scores were also lower in the video laryngoscope group when

 

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compared to the conventional(5). Thus this study concluded that video laryngoscopes

were superior to conventional scopes in this particular setting and that the channeled

scope (Airtraq), faired better than the non channeled scope (CMAC).

Byhahn et al. compared the CMAC video laryngoscope with conventional

laryngoscopy in patients with cervical spine immobilization with the help of a rigid

collar and concluded that laryngeal view was highly enhanced in the video

laryngoscope group when compared to the conventional group(42).

Gupta et al. compared the use of the CMAC video laryngoscope with and without the

use of a stylet to aid in endotracheal tube placement in patients with cervical spine

immobilization. They showed that the use of a stylet significantly reduced intubation

difficulty scores(43).

RoyaYumul et al. compared the CMAC video laryngoscope with the flexible

fibreoptic scope for intubation in patients with cervical spine immobilization. They

concluded that the glottis view did not differ considerably at the time of intubation

between the two scopes but the time for securing the airway was much shorter with

the CMAC video laryngoscope when compared to the flexible fibreoptic scope(44).

Unfortunately, just like fiberoptic intubation, video laryngoscopes may be more

difficult to access in an urgent or emergency situation and may not provide the

expected results if the provider is not skilled with its use or there is blood in the

airway that could reduce the view provided by the camera. Even with these

limitations, some studies proclaim better success rates in the first attempt with video

laryngoscopy than direct laryngoscopy in emergency situations(45).

 

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A systematic review and metaanalysis of multiple randomized control studies by

Suppan et al., comparing various alternative intubation techniques versus Macintosh

laryngoscopy, was done. 24 trials were looked into and 5 alternative intubating

devices were studies in comparison to the Macintosh blade. The 5 devices were the

Airtraq, Airwayscope (channeled), Glidescope, CMAC and the Mcgrath (non

channeled) video laryngoscopes.

The Airtraq was associated with a statistically significant reduction in the risk of

intubation failure in the first attempt. It provided a higher rate of Cormack Lehane

grade 1 laryngoscopy and a reduction in the time of successful intubation. Other

devices were associated with improved glottis visualization but no statistically

significant differences in endotracheal intubation failure or time to intubation

compared with conventional direct laryngoscopy(46).

While the use of MILS has been emphasized sufficiently in limiting cervical spine

motion during intubation, this technique has been shown to make direct laryngoscopy

much more challenging. Thus, the use of video laryngoscopy may allow in an

improved laryngeal view in the setting of MILS; although, it should be emphasized,

that cervical spine motion may be affected as much as with video laryngoscopy as

compared with direct laryngoscopy(17)(47).

Because of the relatively new technology of video laryngoscopy, large trials are still

needed to best conclude if these devices should fit in the management algorithm of a

patient with potential cervical spine injury.

 

38  

The C-MAC video laryngoscope (Fig. 6) is a development of previous video

laryngoscopes by Karl Storz (MVL, V-MAC). It can be compared with the MVL as

described by Kaplan et al(48).It has a Macintosh steel blade shape with a blade design

which is closed. It doesn’t have any edges or gaps for hygienic traps and is available

in three sizes (2, 3, and 4).

The C-MAC blade is flattened, resulting in a slim blade profile (maximum 14

millimeters). The edges are slanted in order to avoid damage to the mouth and teeth

during laryngoscopy. Optionally, the blade can be equipped with a holder channel for

a suction catheter (14–16 Ch).

In contrast to both the MVL and V-MAC, which were based on fiberoptic technique

 

39  

with an external light source, the C-MAC incorporates the smallest possible

(2millimeters) digital camera (Complementary Metal Oxide Semiconductor (320x240

pixels) and a high power light emitting diode, located laterally in the distal third of the

blade.

Reduced image quality due to damaged optical fibers, the need for white balance and

focusing, and immobility due to the external light source were replaced. Compared

with both the MVL and V-MAC, the embedded optical lens has an increased aperture

angle of 80° (Fig. 7). The view obtained includes the tip of the blade and, hence,

allows visual guidance of the tip of the blade into the vallecula.

A color image is displayed on a lightweight, portable high-resolution liquid crystal

display monitor with lithium ion battery technology, permitting around two working

hours without recharging. The image may also be recorded as a single picture or a

video by one touch technique either on the monitor or the video laryngoscope handle.

It can be stored using the secure digital card slot (Fig. 6).

Similar to other video laryngoscopes, a view of the epiglottis and glottis is available

on the video screen as soon as the camera section of the C-MAC enters the

pharynx(49).

 

40  

Figure 6: The C-MAC video laryngoscope. Note the buttons for image recording on

the monitor and the laryngoscope handle. A power cord/video cable, emerging from

the handle, attaches to a dedicated, portable liquid crystal display monitor.

 

41  

Figure 7: Main angulations of the C-MAC blade Size 3 and Size 4, respectively.

 

42  

The D blade of the CMAC system was developed by Dr. Volker Dorges. The primary

distinguishing feature of the D blade is its shape, which is an elliptically tapered blade

rising to the distal. In comparison with the conventional C-MAC blade, which has the

Macintosh shape, the D-Blade is half-moon shaped, resulting in a higher angulation

(40 degrees). It claims to provide easy option in difficult laryngoscopies (Cormack

and Lehane grade 3 and 4)Complications like swelling, haemorrhage and other side

effects of a difficult intubation can be avoided.(Figure 8) (6)

Figure 8:A-Size 3 blade, B-Size 4 blade, C-CMAC D blade.

 

43  

Figure 9:King vision videolaryngoscope

King vision laryngoscope is a type of video laryngoscope with OLED display and

designed to provide minimal lifting of soft tissue and minimize trauma during

intubation. A channeled blade provides port for easy introduction of ET tube.

King vision video laryngoscope is a relatively newer video laryngoscope. Tim Mullen

et al., compared the King vision with the Glidescope in cadavers with and without

cervical immobilization and found similar efficacy between the 2 scopes. He

concluded that an affordable, portable video laryngoscope such as the King vision can

play a crucial role in airway management(50).

 

44  

King vision laryngoscope is an OLED device which was compared with the

Macintosh laryngoscope by Murphy et al and was found to decrease the time to

successful intubation in two of the four studied airway scenarios and had a higher

intubation success rate in difficult cadaver airway scenarios(7).

Jeffery et al., compared the use of the portable King vision video laryngoscopes with

direct laryngoscopy in the emergency setting, out in the field, among health care

professionals and they concluded that the King video laryngoscope improved success

of first attempt endotracheal intubations compared to direct laryngoscopy(51).

Lorenz Theiler, Kristina Hermann et al., in their multi centric prospective randomized

control trial in Switzerland are looking to compare the clinical efficacy of three

channeled video laryngoscopes versus non channeled video laryngoscopes in

simulated difficult airway patients. The channeled video laryngoscopes include

Airtraq, AP advance and King vision. The non channeled video laryngoscopes include

the CMAC, Glidescope and Mcgrath. This prospective trial will throw more light on

the efficiency of these video laryngoscopes especially the newer ones such as the King

vision(52).

Intubation difficulty score (IDS):

The IDS is a subjective description of the difficulty encountered during endotracheal

intubation. It takes into account several factors, which contribute to the difficulty

assessment. The various grades of the scoring system are easy, slightly difficult and

moderately to severe difficulty based on the summation of the subjective scores of the

seven separate questions asked(53).

 

45  

Figure 10:

 

46  

METHODOLOGY

 

47  

METHODOLOGY:

Intervention and Comparator agent: randomized control study comparing 2 video

laryngoscopes, the King vision and the CMAC D blade in patients with cervical spine

immobilization.

Key Criteria

Inclusion Criteria:

1. ASA 1 and 2 patients.

2. Patients with Mallampati 1 and 2, having good neck extension.

(mentum higher than occiput on extension) and no obvious deformities such as buck

teeth, retrognathia, etc.

3. Patients coming for surgery requiring intubation.

4. Patients above 16 years and less than 70 years.

5. Patients with BMI less than 30.

Exclusion Criteria:

1.Patients who do not consent for the study.

2.Anticipated difficult airway, Mallampati 3 and 4, BMI >=30 and limitation of neck

extension.

 

48  

3.ASA 3 and 4 patients.

4.patients at risk for aspiration (hiatus hernia).

Method of randomization:

Computer generated randomization codes were used to allot patients into the 2 groups.

Method of allocation concealment: Closed opaque envelopes.

Blinding and masking: An independent observer (not the anaesthetist on the case)

will note the time for glottis visualization and intubation, along with hemodynamic

response at 0,1,3 and 5 minutes.

Primary Outcome: Time for visualization of the glottis and time for successful

intubation.

Secondary Outcomes: Intubation difficulty score, hemodynamic response and

associated complications

Target sample size and rationale:

Tracheal intubation with a video laryngoscope in patients with cervical spine

immobilization: a randomized trial of the Airwayscope and Glidescope(8). This is a

similar study comparing a channeled and non channeled video laryngoscope. Here the

time for tracheal intubation using the Glidescope (non channeled) was 71.9 sec SD

(47.9) compared to the Airwayscope (channeled) which was 34.2 sec SD (25.1).

 

49  

We assume the time difference between both the scopes is 25 seconds. So the

minimum number of patients to be studied is n=49.

Hence the target sample size for this study is 100,with 50 patients in each arm.

Considering the time difference between both the groups as 25 seconds, number to

treat will be 100.

Two means hypothesis testing for two means

Standard deviation in group 1 48

Standard deviation in group 2 25

Mean difference 25

Effect size 0.6849

Alpha error (%) 5

Power (1-Beta) % 90

1 or 2 sided 2

Required sample size per group 49

 

50  

Methods in detail:

Patients coming to CMC Vellore for surgery and those requiring general anaesthesia

were recruited for surgery. Patients who did not have an anticipated difficult airway

were approached for consent for the study. A computer generated randomization put

patients in two categories. For group 1 King Vision laryngoscope was used and the

other group, CMAC D blade with a stylet was be used for intubation. A standardized

anaesthetic plan was used for all patients prior to intubation.

Patients were pre oxygenated to an ETO2 of more than 90%. Propofol was used as the

induction agent of choice (dose of 2-3mg/kg). Vecuronium (dose of 0.1mg/kg) was

used to facilitate tracheal intubation. Fentanyl was given as a bolus dose of 2mcg/kg.

Manual inline stabilization (MILS) was applied by one of the investigators in all

patients. MILS was applied from the head end of the patient after the induction of

 

51  

anaesthesia and muscle paralysis. Based on randomization, one of the two video

laryngoscopes was used to intubate the trachea. The anaesthetist should have

performed 10 intubations on mannequins to become eligible to perform the intubation

with either device.

After ensuring adequate paralysis, the patient’s trachea was intubated by one of the

trained operators. Laryngoscopy time (time from the introduction of laryngoscope into

the patients mouth to glottis visualization), Intubation time (time from introduction of

the laryngoscope to 3 consecutive waveforms in ETCO2 or visualizing the black line

on the tube go past the cords) was recorded by an independent observer (not the

anaesthetist on the case). Intubation Difficulty scale (IDS) was graded based on the

subjective ease of intubation by the anaesthetist who intubated the patient.

Base line monitoring included heart rate, systolic blood pressure and Diastolic blood

pressure at 0 minutes. These variables were measured again at 1,3 and 5 minutes after

successful intubation.

In case of failure to intubate with the study device, external laryngeal manipulation

was used to facilitate intubation. If failed again, MILS was discontinued, head

extension was used along with external laryngeal manipulation and the patient was

intubated with the McCoy laryngoscope (rescue laryngoscope), with the help of a

senior consultant. All the data was analyzed and seen if one scope is better than the

other in potential C spine disease patients.

 

52  

Statistical methods used to analyze data:

Data was entered using EPIDATA software. Data was screened for outliers and

extreme values using Box-Cox plot and histogram (for shape of the distribution). All

baseline variables were expressed in terms of mean ± SD if they were continuous

variables. All categorical variables were reported using frequencies and

percentages. Mann-Whitney U test was used to compare Scope with time1, time2 and

time difference. Chi-square test performed for categorical variables and the outcome

variable, scope. ANOVA was done where outcome had more than two groups.

Differences were considered significant at p<0.05. All the statistical analysis was

performed using SPSS 18.0.

 

53  

STROBE FIGURE

 

54  

RESULTS

 

55  

RESULTS:

A total of 100 patients were included for the study with the ages ranging from 16-70

years. The mean age was 33 years (SD of 11.04). The maximum age of all the patients

enrolled was 64 years and the minimum age was 16 years.

Table 1: Gender distribution

Gender

Frequency

n %

Male 61 61.0

Female 39 39.0

Total 100 100.0

The gender distribution table showed a male predominance of 61% (table 1).

 

56  

Table 2: Video laryngoscope distribution

Scope

Frequency

n %

King Vision 50 50.0

CMAC D blade 50 50.0

Total 100 100.0

Out of the 100 patients enrolled in the study, the distribution among the patients who

were intubated with King Vision video laryngoscope as compared to the CMAC D

blade were the same (table 2).

Table 3: Experience of the operator

Experience Frequency

n %

<2 years 1 1.0

2-5 years 64 64.6

>5 years 34 34.3

Total 99 100.0

Of the anaesthetists taking part in the study, 64.6% had experience of 2-5 years and

34.3% had experience of more than 5 years (Table 3).

 

57  

Table 4: Body mass index (BMI) of the subjects

BMI

Frequency

N %

<= 25 78 83.9

> 25 15 16.1

Total 93 100.0

Majority of the subjects in the study had a BMI of less than or equal to 25 (83.9%)

and the remaining 16.1% of the subjects had a BMI of more than 25 and less than 30

(Table 4).

 

58  

Table 5:

Time Scope Frequency(n) Mean(secs) SD(secs) P value

T1 (time to

visualize the glottis)

King vision 47 22.43 +12.65

<0.001

CMAC D 47 13.60 +10.89

T2 (time for

intubation)

King vision 47 33.21 +15.34

0.232 CMAC D 47 37.62 +19.88

T diff (T2 – T1)

King vision 47 10.78 +7.10

<0.001

CMAC D 47 24.02 +14.91

Unable to intubate 6 -

Total 100 -

On analyzing (table 5) the time to visualize the glottis (T1) between the two video

laryngoscopes, CMAC D blade had a shorter duration (13.60sec) compared to King

vision (22.43sec) p value (<0.001). The time for intubation of the airway (T2) was

similar between the two scopes while the time between visualization of glottis and

intubation of the airway (T diff) was shorter for King vision (10.78 sec) as compared

to CMAC D blade (24.02 sec) p value (<0.001).6 patients out of the total couldn’t be

intubated with the study scope and the rescue laryngoscope had to be used (Mccoy

laryngoscope).

 

59  

Figure 11: Bar graph showing a comparison between the mean time in seconds for

visualizing the glottis (mean time 1), versus the two study video laryngoscopes

(scope).

 

60  

Figure 12: Bar graph showing a comparison between the mean time in seconds for

intubation of the airway (mean time 2), versus the two study video laryngoscopes

(scope)

 

61  

Figure 13: Bar graph showing a comparison between the mean time difference from

visualization of glottis and intubation of the airway in seconds (mean time_diff),

versus the two study video laryngoscopes (scope)

 

62  

Table 6:

IDS (intubation difficulty

scale)

King vision CMAC D

n % n %

Easy(0) 26 55.3 10 21.7

Slightly difficult(1-5) 21 44.7 36 78.3

Total 47 100.0 46 100.0

P value-0.001 The subjective grading for the difficulty in intubation (IDS) was compared between

King vision and CMAC D video laryngoscopes (Table 6). In the King vision group,

55.3% of the intubations were ‘Easy’ and 44.7% were ‘Slightly difficult’.

In the CMAC D group, 21.7% of the intubations were ‘Easy’ and 78.3% were

‘Slightly difficult’.

This comparison is statistically significant (P value-0.001)

 

63  

Figure14: Bar graph showing a comparison between the intubation difficulty scale

(IDS) and the two video laryngoscopes.

 

64  

Table 7:

Inability to intubate

King vision CMAC D

n % n %

Yes 4 8.0 2 4.1

No 46 92.0 47 95.0

Total 50 100.0 49 100.0

P value-0.414 Out of the 50 patients in the King vision group, 8% (n=4) could not be intubated with

the study scope and required the use of the rescue laryngoscope.

Out of the 49 patients (missing data-1) in the CMAC D group, 4.1% (n=2) could not

be intubated with study scope and required the use of the rescue laryngoscope.

Table 8:

External pressure applied

King vision CMAC D

n % n %

Yes 15 31.2 30 63.8

No 33 68.8 17 36.2

Total 48 100.0 47 100.0

P value-0.001 In the King vision group, 31.2% (n=15) required external laryngeal pressure to aid in

tracheal intubation.

In the CMAC D group, 63.8% (n=30) required external laryngeal pressure to aid in

tracheal intubation. This comparison is statistically significant (P value-0.001).

 

65  

Table 9:

Number of attempts King vision CMAC D

n % n %

1 42 85.7 45 95.7

2 7 14.3 2 4.3

Total 49 100.0 47 100.0

P value-0.092 In the King vision group, 85.7%(n=42) required 1 attempt to intubate the trachea

while 14.3%(n=7) required 2 attempts to intubate the patient.

In the CMAC D group, 95.7%(n=45) required 1 attempt to intubate the patient while

4.3%(n=2) required 2 attempts to intubate the patient.

Table 10:

Rescue laryngoscope

King vision CMAC D

n % n %

Yes 4 7.8 2 4.1

Not applicable 47 92.2 47 95.9

Total 51 100.0 49 100.0

P value-0.085 In the King vision group, 7.8%(n=4) required the use of the rescue laryngoscope

while in the CMAC D group, 4.1%(n=2) required the use of the rescue laryngoscope.

 

66  

Table 11:

Complications Frequency(n) %

Anterior larynx 2 2

Inability to introduce scope 4 4

Superficial cut on lip 1 1

Bronchospasm 1 1

Total complication-8% The complication rate was 8%(n=8) across both the study video laryngoscopes.

 

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Table 12: King Vision group:

BMI(<=25) N=40

Time 1(sec) Time 2(sec) Time diff(sec)

Mean 21.73 31.80 10.07

S.D 12.582 14.77 6.49

BMI(>25) N=4

Mean 30.25 50.75 20.50

S.D 16.21 14.72 8.42

P value 0.205 0.030 0.013

In the King vision group, the mean time to visualize the glottis(Time 1) for patients

with BMI<=25 and BMI>25 were 21.73 seconds and 30.25 seconds respectively. The

comparison is not statistically significant (p value-0.205).

Whereas the mean time for tracheal intubation (Time 2) for patients with BMI<=25

was 31.80 seconds and those patients with BMI>25 was 50.75 seconds. This

comparison is statistically significant (p value-0.030).

The mean time difference between visualization of the glottis and tracheal intubation

(Time diff) was 10.07 seconds in patients with BMI<=25 and 20.50 seconds in

patients with BMI>25.This comparison is statistically significant (p value-0.013).

 

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Table 13: CMAC D group:

BMI(<=25) N= 36

Time 1(sec) Time 2(sec) Time diff(sec)

Mean 11.42 35.56 24.13

S.D 6.62 17.72 15.06

BMI(>25) N=10

Mean 21.80 46 24.20

S.D 18.46 26.31 15.80

P value 0.011 0.220 0.947

In the CMAC D group, the mean time to visualize the glottis (Time 1) for patients

with BMI<=25 and BMI>25 were 11.42 seconds and 21.80 seconds respectively. The

comparison is statistically significant (p value-0.011). The mean time for tracheal

intubation (Time 2) for patients with BMI<=25 was 35.56 seconds and those patients

with BMI>25 was 46 seconds. This comparison is not statistically significant (p

value-0.220).

The mean time difference between visualization of the glottis and tracheal intubation

(Time diff) was 24.13 seconds in patients with BMI<=25 and 24.20 seconds in

patients with BMI>25.This comparison is not statistically significant (p value-0.947).

 

69  

Figure 15:Line graph showing the comparison between the mean time to visualize the

glottis (Mean time 1) and BMI (BMIR) between the two study video laryngoscopes.

 

70  

Figure 16: Figure 5:Line graph showing the comparison between the mean time to

intubate the trachea (Mean time 2) and BMI (BMIR) between the two study video

laryngoscopes.

 

71  

Figure 17: Line graph showing the comparison between the mean time difference

between visualization of glottis and tracheal intubation (Mean time _diff) and BMI

(BMIR) between the two study video laryngoscopes.

 

72  

Table 14: King Vision:

Experience (2-5 years)

N=32

Time 1(sec) Time 2(sec) Time diff(sec)

Mean 20.56 30.31 9.75

S.D 12.37 14.94 7.04

Experience (>5 years) N=15

Mean 26.40 39.40 13.0

S.D 12.73 14.77 6.95

P value 0.174 0.046 0.108

In the King vision group, the mean time to visualize the glottis (Time 1) for

anaesthetists with 2-5 years experience and those with >5 years experience were 20.56

seconds and 26.40 seconds respectively. The comparison is not statistically significant

(p value-0.174).

The mean time for tracheal intubation (Time 2) for anaesthetists with 2-5 years

experience was 30.31 seconds and those with >5 years experience was 39.50 seconds.

This comparison is statistically significant (p value-0.046).

The mean time difference between visualization of the glottis and tracheal intubation

(Time diff) was 9.75 seconds in patients intubated by anaesthetists with 2-5 years

experience and 13 seconds in patients who were intubated by anaesthetists with >5

years experience. This comparison is not statistically significant (p value-0.108).

 

73  

Table 15: CMAC D:

Experience (2-5 years) N=36

Time 1(sec) Time 2(sec) Time diff(sec)

Mean 11.93 35.82 23.89

S.D 6.51 16.29 15.47

Experience (>5 years) N=10

Mean 16.28 41.28 25

S.D 15.53 24.77 14.45

P value 0.88 0.56 0.45

In the CMAC D group, the mean time to visualize the glottis (Time 1) for

anaesthetists with 2-5 years experience and those with >5 years experience were 11.93

seconds and 16.28 seconds respectively. The comparison is not statistically significant

(p value-0.88).

The mean time for tracheal intubation (Time 2) for anaesthetists with 2-5 years

experience was 35.82 seconds and those with >5 years experience was 41.28 seconds.

This comparison is not statistically significant (p value-0.56).

The mean time difference between visualization of the glottis and tracheal intubation

(Time diff) was 23.89 seconds in patients intubated by anaesthetists with 2-5 years

experience and 25 seconds in patients who were intubated by anaesthetists with >5

years experience. This comparison is not statistically significant (p value-0.45).

 

74  

Figure 18: Line graph showing the comparison between the mean time to visualize the

glottis (Mean time 1) and experience of the anaesthetist (Exp) between the two study

video laryngoscopes.

 

75  

Figure 19: Figure 5:Line graph showing the comparison between the mean time to

intubate the trachea (Mean time 2) and experience of the anaesthetist (Exp) between

the two study video laryngoscopes.

 

76  

Figure 20: Line graph showing the comparison between the mean time difference

between visualization of glottis and tracheal intubation (Mean time _diff) and

experience of the anaesthetist (Exp), between the two study video laryngoscopes.

 

77  

Table 16:

King Vision:

(n=48)

HR (sec) Systolic BP(mm Hg)

0 Minute (baseline)

Mean 79.69 122.58

S.D 13.66 14.25

1 minute Mean 88.83 127.85

S.D 13.05 14.51

3 minutes Mean 82.23 115.27

S.D 11.82 15.08

5 minutes Mean 79.90 104.48

S.D 11.88 14.31

This table shows the mean heart rate and mean systolic blood pressure at baseline and

1, 3 and 5 minutes post intubation with the King vision video laryngoscope.

 

78  

Table17:

CMAC D:

(n=47)

HR (sec) Systolic BP(mm Hg)

0 Minute (baseline)

Mean 81.47 119.09

S.D 15.02 17.10

1 minute Mean 89.21 125.60

S.D 15.60 16.15

3 minutes Mean 83.32 112.72

S.D 13.64 15.49

5 minutes Mean 80.47 104.60

S.D 12.32 12.10

This table shows the mean heart rate and mean systolic blood pressure at baseline and

1, 3 and 5 minutes post intubation with the CMAC D video laryngoscope.

 

79  

Figure 21: Line graph comparing the mean heart rate at baseline and 1, 3 and 5

minutes post intubation with the two study video laryngoscopes.

 

80  

Figure 22: Line graph comparing the mean systolic blood pressure at baseline and 1, 3

and 5 minutes post intubation with the two study video laryngoscopes.

 

81  

DISCUSSION

 

82  

DISCUSSION:

Two relatively new video laryngoscopes were used in patients with simulated cervical

spine injury using manual inline stabilization (MILS). A total of 100 patients were

recruited for the study and evenly distributed among the two study groups. The gender

distribution showed a male predominance. The majority of the study cases were

performed by the primary investigator, who had anaesthetic experience of 2-5 years.

The remaining cases were performed by anaesthetists, who had experience of more

than 5 years. Majority of the patients had BMI of less than or equal to 25.

The primary objective of the study was to analyze the time required for visualization

of the glottis and the time required for intubation of the trachea in patients with

simulated cervical spine injury using MILS. In this study we found that the time to

visualize the glottis was shorter in the CMAC D blade group (13.60 secs) as compared

to the King vision group (22.43 secs)(p value-<0.001). Liu et al. on the other hand

showed similar times for visualization of the glottis between both the channeled and

non channeled video laryngoscope groups (8). They also mentioned that the operators

performing the study had similar experience with both the scopes.

The King vision video laryngoscope is a new device in our department whereas the

CMAC video laryngoscope has been used for around 2 years prior to this study. Every

new device requires a learning curve and this is one of the reasons for the longer time

required to visualize the glottis. The King vision video laryngoscope is a channeled

scope which has a slot on the blade to mount the endotracheal tube before intubation.

This makes the scope considerably thicker than the CMAC D blade. Introduction of

 

83  

the scope into the mouth posed an issue especially in patients whose cervical spine

was stabilized with manual inline stabilization (MILS). This is another reason why the

time for glottis visualization was prolonged when the King vision scope was used as

compared to the CMAC D blade.

The time for intubation of the airway was marginally shorter in the King vision group

(p value-0.232) but the time between visualization of glottis and intubation of the

airway was considerably shorter in the King vision group (10.78 secs) as compared to

the CMAC D blade group (24.02 secs)(p value-<0.001). The King vision video

laryngoscope, being a channeled scope, required a mere guidance of the endotracheal

tube through the glottis as compared to the CMAC D blade group where the

endotracheal tube with stylet in situ needed to be negotiated through the mouth and

guided through the glottis after removal of the stylet. Liu et al. and Laffey et al.

showed similar results in their respective studies(8)(5). They also showed a shorter

time to intubation of the airway in the channeled video laryngoscope group as

compared to the non channeled group. In our study, the time taken to intubate the

trachea was shorter in the channeled group as compared to the non channeled group

but the time difference between the groups was not statistically significant (p value-

0.232).

Anaesthetists who had performed a minimum of 10 intubations with both scopes on a

mannequin were allowed to take part in this study. Experience of the anaesthetist

based on number of years of anaesthesia exposure was also analyzed. Majority of the

 

84  

cases were performed by the primary investigator of the study (64.6%), who had an

experience of 2-5 years.

As mentioned earlier, both the King vision video laryngoscope and the CMAC D

video laryngoscope are relatively new devices in our department. In the King vision

group, the mean time taken to intubate the airway was shorter in the experience

category of 2-5 years (30.31secs) as compared to the experience category of more

than 5 years (39.40 secs) (p value- 0.046).

As the King vision scope is a very new device in our department, it requires a learning

curve for familiarity and skill. The primary investigator performed majority of the

cases, which explains the shorter time taken to intubate the airway. On the contrary, in

the CMAC D group, the time taken to intubate the airway showed a negligible

difference (p value- 0.56) between the two experience categories, as the operators

were more familiar with the concerned scope. Liu et al., in their study have mentioned

that operators had moderate experience with both the study scopes(8).

Patients were categorized as those with a body mass index (BMI) less than or equal to

25 and those with a BMI greater than 25. In the King vision group, mean time to

intubation of the airway was shorter (31.80 secs) in those with BMI <= 25 as

compared to those with a BMI >25 (50.75 secs). The King vision scope, as seen in the

picture provided, has the viewing screen mounted on top of the handle of the scope.

This makes the whole device considerably longer as compared to the CMAC D

device. In patients with BMI more than 25, there was difficulty in introduction of the

scope due to hindrance from the anterior chest, more prominent in those with a higher

 

85  

BMI. On the other hand there was no such problem encountered with the CMAC D

blade, which showed shorter times for both visualization of the glottis and intubation

of the airway. Thus the CMAC D blade performed better than King vision video

laryngoscope in patients with a BMI> 25.

Optimization maneuvers such as external laryngeal pressure aid in improving the

process of laryngoscopy. In our study, optimization maneuvers were applied only

when required. The frequency of usage of a maneuver was studied between both video

laryngoscope groups. In the CMAC D group, 63.8% of the patients required external

laryngeal pressure to aid in laryngoscopy as compared to only 31.2% in the King

vision group (p- 0.001). Laffey et al., also showed in their study that optimization

maneuvers were less frequently used in channeled video laryngoscopes as compared

to non channeled video laryngoscopes(5).

The intubation difficulty scale (IDS) is a subjective description of the difficulty

encountered during endotracheal intubation. It takes into account several factors,

which contribute to the difficulty assessment. The various grades of the scoring

system are ‘easy’, ‘slightly difficult’ and ‘moderately to severe difficulty’ based on

the summation of the subjective scores of the seven separate questions asked. The IDS

was compared between both the video laryngoscope groups. 78.3% of the

anaesthetists found it ‘slightly difficult’ to intubate the airway in the CMAC D group

compared to only 21.7%, who found it ‘easy’ to intubate the airway. In the King

vision group, 44.7% of the operators found it ‘slightly difficult’ as compared to 55.3%

who found it ‘easy’ to intubate the airway (p value-0.001)

 

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In the King vision group, 85.7% of the patients could be intubated in the first attempt

while 14.3% required two attempts at successful intubation. In the CMAC D group,

95.7% of the patients could be intubated in the first attempt while 4.3%of patients

required two attempts for intubation. None of the patients in either group required

more than 2 attempts at intubation. 8% of the patients in the King vision group could

not be intubated with the study scope, while only 4.1% of patients in the CMAC D

group could not be intubated with the study scope. Rescue laryngoscope was used in

these circumstances with 100% success in the first attempt.

The King vision laryngoscope was found difficult to introduce into the mouth of

patients who had their cervical spines stabilized with MILS. As mentioned before, the

thickness of the channeled blade caused difficulty in introduction of the blade into the

mouth. The increased length of the scope, as it has the viewing screen mounted on top

of the handle, made it difficult to introduce into the mouth as the anterior chest

hindered the process of laryngoscopy. Once the King vision video laryngoscope was

introduced into the mouth, glottis visualization and intubation of the trachea required

less external laryngeal manipulation and was easier to perform as compared to the

CMAC D blade.

Hemodynamic response to intubation in both the groups were similar. The primary

determinant of laryngoscopic response to intubation is the time taken to intubate.

Laryngoscopic response to intubation starts at 15 seconds and reaches a peak at 45

seconds. In our study we found the mean time to intubation of the airway, similar in

both the study groups. The second determinant is the pressure on the base of the

 

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tongue. Since both the devices we compared are video laryngoscopes with angled tips,

the pressure exerted may have been less than the conventional Macintosh scope. We

cannot convincingly state this, as we did not measure the pressure exerted on the

tongue.

Haemodynamic response in both Liu et al. and Laffey at al.’s study showed no

difference between the channeled and non channeled scope to laryngoscopy(8)(5).

The complication rate was 8% across both the study groups. Inability to introduce the

scope into the mouth was the highest with 4% and all the cases involved the King

vision laryngoscope. Anteriorly placed larynx was the next highest with 2% and both

the cases involved the CMAC D scope. The other complications included a superficial

cut on the lip and a case of post laryngoscopy bronchospasm, which settled with

positive pressure ventilation and salbutamol nebulization.

 

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CONCLUSION

 

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CONCLUSION:

1) The king vision video laryngoscope, being a channeled scope was difficult to

introduce into the mouth of the patient during laryngoscopy due to the

thickness of the blade and the cervical immobility (MILS) provided to the

patient. The CMAC D blade on the other hand, did not have such problem in

scope introduction.

2) Once introduced into the mouth of the patient, less optimization maneuvers

were required for the King vision video laryngoscope. The ease of endotracheal

intubation, as provided by the IDS scale, was better for the King vision as

compared to the CMAC D video laryngoscope.

3) The CMAC D blade performed better than the King vision video laryngoscope

in patients with a higher body mass index (>25).

4) Haemodynamic response to intubation was similar in both the video

laryngoscope groups

5) Complication rate was negligible in both the video laryngoscope groups.

6) Like any new airway equipment, the King vision video laryngoscope required a

learning curve for familiarity and skill.

 

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LIMITATIONS:

1) The potential for bias exits as it is impossible to blind the operator to the video

laryngoscope.

2) The ease of intubation, as provided by the IDS, is a subjective scale.

3) The IDS was mainly constituted for direct laryngoscopy, its efficacy in indirect

laryngoscopy is less clear.

4) The King vision was relatively new in our department while the CMAC video

laryngoscope was in use for 2 years prior to the study.

5) Manual in line stabilization alone is not a foolproof method to provide cervical

spine immobilization.

 

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FUTURE RESEARCH:

The efficacy of the IDS in indirect laryngoscopy can be substantialized with further

research.

 

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4. Bathory (last), Frascarolo. EvaluationoftheGlideScope for tracheal intubation in patients with cervical spine immobilisation by a semi-rigid collar. Anaesthesia. 2009;64:1337-41.

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9. Crosby ET, Lui A. The adult cervical spine: implications for airway management. Can J Anaesth. 1990;37(1):77–93.

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17. Robitaille A, Williams SR, Tremblay M-H, Guilbert F, Thériault M, Drolet P. Cervical Spine Motion During Tracheal Intubation with Manual In-Line Stabilization: Direct Laryngoscopy versus GlideScope® Videolaryngoscopy: Anesth Analg. 2008 Mar;106(3):935–41.

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19. Podolsky S, Baraff LJ, Simon RR, Hoffman JR, Larmon B, Ablon W. Efficacy of cervical spine immobilization methods. J Trauma. 1983 Jun;23(6):461–5.

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27. Mort TC. Esophageal intubation with indirect clinical tests during emergency tracheal intubation: a report on patient morbidity. J Clin Anesth. 2005 Jun;17(4):255–62.

28. Nolan JP, Wilson ME. Orotracheal intubation in patients with potential cervical spine injuries. An indication for the gum elastic bougie. Anaesthesia. 1993 Jul;48(7):630–3.

29. Holley J, Jorden R. Airway management in patients with unstable cervical spine fractures. Ann Emerg Med. 1989 Nov;18(11):1237–9.

30. Rosenblatt WH, Wagner PJ, Ovassapian A, Kain ZN. Practice patterns in managing the difficult airway by anesthesiologists in the United States. Anesth Analg. 1998 Jul;87(1):153–7.

31. Malcharek MJ, Rogos B, Watzlawek S, Sorge O, Sablotzki A, Gille J, et al. Awake fiberoptic intubation and self-positioning in patients at risk of secondary cervical injury: a pilot study. J Neurosurg Anesthesiol. 2012 Jul;24(3):217–21.

32. Yeganeh N, Roshani B, Azizi B, Almasi A. Target-controlled infusion of remifentanil to provide analgesia for awake nasotracheal fiberoptic intubations in cervical trauma patients. J Trauma. 2010 Nov;69(5):1185–90.

33. Avitsian R, Lin J, Lotto M, Ebrahim Z. Dexmedetomidine and awake fiberoptic intubation for possible cervical spine myelopathy: a clinical series. J Neurosurg Anesthesiol. 2005 Apr;17(2):97–9.

34. Stephens CT, Kahntroff S. The success of emergency endotracheal intubation in trauma patients: A 10-year experience at a major adult trauma referral center. Anesth Analg 2009;109:866-72.

35. Ong J-R, Chong C-F, Chen C-C, Wang T-L, Lin C-M, Chang S-C. Comparing the performance of traditional direct laryngoscope with three indirect laryngoscopes: A prospective manikin study in normal and difficult airway scenarios. Emerg Med Australas EMA. 2011 Oct;23(5):606–14.

 

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36. Keller C, Brimacombe J, Keller K. Pressures exerted against the cervical vertebrae by the standard and intubating laryngeal mask airways: a randomized, controlled, cross-over study in fresh cadavers. Anesth Analg. 1999 Nov;89(5):1296–300.

37. Kihara S, Watanabe S, Brimacombe J, Taguchi N, Yaguchi Y, Yamasaki Y. Segmental cervical spine movement with the intubating laryngeal mask during manual in-line stabilization in patients with cervical pathology undergoing cervical spine surgery. Anesth Analg. 2000 Jul;91(1):195–200.

38. Arslan ZI, Yildiz T, Baykara ZN, Solak M, Toker K. Tracheal intubation in patients with rigid collar immobilisation of the cervical spine: a comparison of Airtraq® and LMA CTrachTM devices*. Anaesthesia. 2009 Dec 1;64(12):1332–6.

39. Gerstein NS, Braude DA, Hung O, Sanders JC, Murphy MF. The Fastrach Intubating Laryngeal Mask Airway: an overview and update. Can J Anaesth J Can Anesth. 2010 Jun;57(6):588–601.

40. Galgon R, Schroeder K, Joffe A, Shepler J. Validation of the unassisted, gum-elastic bougie-guided, laryngeal mask airway-ProSealTM placement technique in anaesthetized patients. Indian J Anaesth. 2012;56(3):255.

41. Brück S, Trautner H, Wolff A, Hain J, Mols G, Pakos P, et al. Comparison of the C-MAC ® and GlideScope ® videolaryngoscopes in patients with cervical spine disorders and immobilisation. Anaesthesia. 2015 Feb;70(2):160–5.

42. Byhahn C, Iber T, Zacharowski K, Weber CF, Ruesseler M, Schalk R, et al. Tracheal intubation using the mobile C-MAC video laryngoscope or direct laryngoscopy for patients with a simulated difficult airway. Minerva Anestesiol. 2010 Aug;76(8):577–83.

43. Gupta N, Rath GP, Prabhakar H. Clinical evaluation of C-MAC videolaryngoscope with or without use of stylet for endotracheal intubation in patients with cervical spine immobilization. J Anesth. 2013 Oct;27(5):663–70.

44. Yumul R, Elvir-Lazo OL, White PF, Durra O, Ternian A, Tamman R, et al. Comparison of the C-MAC video laryngoscope to a flexible fiberoptic scope for intubation with cervical spine immobilization. J Clin Anesth. 2016 Jun;31:46–52.

45. Mosier JM, Stolz U, Chiu S, Sakles JC. Difficult airway management in the emergency department: GlideScope videolaryngoscopy compared to direct laryngoscopy. J Emerg Med. 2012 Jun;42(6):629–34.

46. Suppan L, Tramèr MR, Niquille M, Grosgurin O, Marti C. Alternative intubation techniques vs Macintosh laryngoscopy in patients with cervical spine immobilization: systematic review and meta-analysis of randomized controlled trials. Myles PS, editor. Br J Anaesth. 2016 Jan;116(1):27–36.

 

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47. Aziz M. Airway Management in Neuroanesthesiology. Anesthesiol Clin. 2012 Jun;30(2):229–40.

48. Kaplan MB, Hagberg CA, Ward DS, Brambrink A, Chhibber AK, Heidegger T, et al. Comparison of direct and video-assisted views of the larynx during routine intubation. J Clin Anesth. 2006 Aug;18(5):357–62.

49. Niforopoulou P, Pantazopoulos I, Demestiha T, Koudouna E, Xanthos T. Video-laryngoscopes in the adult airway management: a topical review of the literature: Video-laryngoscopes in airway management. Acta Anaesthesiol Scand. 2010 Oct;54(9):1050–61.

50. Mullen T, Scott J. COMPARING EFFICACY OF KING VISION AND GLIDESC OPE IN CADAVERS. Br J Anae Sth 2011. 106:613–616.

51. Jarvis JL, McClure SF, Johns D. EMS Intubation Improves with King Vision Video Laryngoscopy. Prehosp Emerg Care. 2015 Oct 2;19(4):482–9.

52. Theiler L, Hermann K, Schoettker P, Savoldelli G, Urwyler N, Kleine-Brueggeney M, et al. SWIVIT-Swiss video-intubation trial evaluating video-laryngoscopes in a simulated difficult airway scenario: study protocol for a multicenter prospective randomized controlled trial in Switzerland. Trials. 2013;14(1):1.

53. Seo S-H, Lee J-G, Yu S-B, Kim D-S, Ryu S-J, Kim K-H. Predictors of difficult intubation defined by the intubation difficulty scale (IDS): predictive value of 7 airway assessment factors. Korean J Anesthesiol. 2012;63(6):491.

 

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APPENDIX:

DATA SHEET A randomised control study comparing the Kings vision laryngoscope and CMAC d blade in patients with C spine immobilisation. 1.Serial no: 2.Name: 3.Hospital no: 4.Age: 5.Sex 6.Laryngoscope used 7.Time taken to visualise the glottis: 8.Time taken to intubate: 9.Experience of the operator: a.<2 years b.2-5 years c.>5years 10.Vitals 0 1 3 5 (mins) heart rate : blood pressure : 11.Number of attempts: 12.External laryngeal manipulation: Y/N 13.Inability to intubate with study scope:Y/N 14.Rescue laryngoscope success:Y/N 15.Any complication(trauma/desaturation/aspiration):  

INTUBATION DIFFICULTY SCALE SCORE Serial no factors score

1 I. N1 NUMBER OF ADDITIONAL INTUBATION ATTEMPTS

additional attempts adds 1 pt  

 

2 N2 NUMBER OF ADDITIONAL OPERATORS each additional operator adds 1 pt  

 

 

98  

3 N3 NUMBER OF ALTERNATIVE INTUBATION TECHNIQUES USED each add 1 pt  

 

4 N4 LARYNGOSCOPIC VIEW AS DEFINED BY CORMACK AND LEHANE GRADE 1: N4 =0. GRADE 2: N4 =1.

GRADE 3: N4 =2. GRADE 4, N4 =3  

 

5 N5 LIFTING FORCE APPLIED DURING LARYNGOSCOPE. N5 =0 IF INCONSIDERABLE.

N5 =1 IF CONSIDERABLE

 

6 N6 NEEDED TO APPLY EXTERNAL LARYNGEAL PRESSURE FOR OPTIMIZED GLOTTIC EXPOSURE. N6 =0 IF NO EXTERNAL PRESSURE OR ONLY THE SELLICK MANEUVER WAS APPLIED.

N6 =1 IF EXTERNAL LARYNGEAL PRESSURE WAS

USED

 

7 N7 POSITION OF THE VOCAL CORDS AT INTUBATION. N7 =0 IF ABDUCTED OR NOT VISIBLE.

N7 =1 IF ADDUCTED

 

Total TOTAL N1 To N7    

 

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PATIENT INFORMATION BROCHURE Study   Title:Arandomised   control   study   comparing   the   Kings   vision   video  laryngoscope  and  the  D  blade  of  the  CMAC  video  laryngoscope    in  patients  with  C  spine  immobilisation.   WHAT IS THE STUDY? You are scheduled to undergo surgery under general anaesthesia.For giving you general anaesthesia,we need to put a tube in your wind pipe using an equipment called a laryngoscope and this procedure is called intubation.In this study we would be using a specialised laryngoscope called the video laryngoscope which provides better visualisation of the airway structures during insertion of the tube according to published literature.The CMAC video laryngoscope will be compared with Kings vision video laryngoscope during this study.Your neck will be held still during intubation and this will help us to identify which scope will be better in patients with C spine problems, at the end of the study.We would be assessing the time taken for insertion of the tube into the wind pipe and also the ease with which it is inserted.Your heart rate and blood pressure will also be monitored during the intubation procedure. IS THERE ANY DANGER BY RECRUITING MYSELF FOR THE STUDY? There is no additional danger by enrolling yourself for the study .Infact video laryngoscopes provide better visualisation of the airway structures compared to the conventional laryngoscope.Your participation in the study is entirely voluntary.You have the right to withdraw from the study at any time.If you do not wish to participate in the study,it will not affect your surgery in any way.The traditional laryngoscope will then be used as per institutional policy. IS THERE ANY EXTRA COST I HAVE TO BEAR TO BE IN THE STUDY? There are no extra charges you need to bear to be in the study.The usual charges for general anaesthesia only have to be paid. WHAT IS THE USE OF THIS STUDY? This study will help us identify which video laryngoscope is better for intubation in patients with C spine problems undergoing general anaesthesia. WILL MY NAME AND OTHER DETAILS BE KEPT CONFIDENTIAL? None of your personal details will be revealed to anyone. DO YOU DOCTORS HAVE ENOUGH EXPERIENCE IN USING THESE EQUIPMENT?

 

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Yes all anaesthetists who participate in this study have undergone training in usage of these equipment. DR JACOB CHANDY DR SAJAN PHILIP GEORGE CONTACT-09894117185

 

101  

Informed Consent form to participate in a research study Study Title:Arandomised control study comparing the Kings vision video laryngoscope and the D blade of the CMAC video laryngoscope in patients with C spine immobilisation. Study Number: ____________ Subject’s Initials: __________________ Subject’s Name: _________________________________________ Date of Birth / Age: ___________________________

(Subject) (i) I confirm that I have read and understood the information sheet dated ____________

for the above study and have had the opportunity to ask questions. [ ] (ii) I understand that my participation in the study is voluntary and that I am free to

withdraw at any time, without giving any reason, without my medical care or legal rights being affected. [ ]

(iii) I agree not to restrict the use of any data or results that arise from this study provided

such a use is only for scientific purpose(s). [ ] (iv) I agree to the use of either of the two video laryngoscopes for general anaesthesia as

per the study.[ ] (v) I agree to my neck being held still during the use of the video laryngoscope as per the

study.[ ] (vi) I agree to take part in the above study. [ ] Signature (or Thumb impression) of the Subject/Legally Acceptable Date: _____/_____/______ Signatory’s Name: _________________________________ Signature: Or

 

102  

Representative: _________________ Date: _____/_____/______ Signatory’s Name: _________________________________ Signature of the Investigator: ________________________ Date: _____/_____/______ Study Investigator’s Name: _________________________ Signature or thumb impression of the Witness: ___________________________ Date: _____/_____/_______ Name & Address of the Witness: ______________________________

 

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MASTER CHART:  

SN   HNO   NAME   AGE   SEX   SCOPE   Time1   Time2   EXP  

97.00   149002d   elavarasi   31.00   2.00   1.00   #NULL!   #NULL!   3.00  

34.00   622812g   shilapaul   16.00   2.00   1.00   20.00   25.00   3.00  

50.00   601843g   gurunath   16.00   1.00   1.00   14.00   19.00   3.00  

19.00   452171g   geetha   43.00   2.00   1.00   30.00   42.00   3.00  

36.00   636833g   padmakumari   23.00   2.00   1.00   #NULL!   #NULL!   2.00  

71.00   437544g   md.showkathali   33.00   1.00   1.00   #NULL!   #NULL!   2.00  

24.00   520334g   vijaya   32.00   2.00   1.00   40.00   44.00   2.00  

69.00   401501g   asitpal   36.00   1.00   1.00   24.00   36.00   2.00  

75.00   481139g   keerthika   17.00   2.00   1.00   22.00   34.00   2.00  

47.00   632413g   seema   32.00   2.00   1.00   14.00   33.00   2.00  

94.00   600052g   deepali   29.00   2.00   1.00   13.00   19.00   2.00  

23.00   611354g   devendra  saw   16.00   1.00   1.00   15.00   26.00   2.00  

46.00   646892g   shimuchowdhury   34.00   1.00   1.00   24.00   32.00   2.00  

99.00   499301g   thenmozhi   31.00   2.00   1.00   18.00   27.00   2.00  

92.00   495315g   ananth   35.00   1.00   1.00   12.00   17.00   2.00  

53.00   643995g   krishnaprasad   50.00   1.00   1.00   15.00   22.00   2.00  

56.00   443057g   salilmira   42.00   1.00   1.00   22.00   36.00   2.00  

31.00   605639g   abhishekkumar   25.00   1.00   1.00   14.00   27.00   2.00  

61.00   464276g   munawar   22.00   1.00   1.00   11.00   18.00   2.00  

79.00    

vivek   20.00   1.00   1.00   24.00   32.00   2.00  

74.00   600215g   mahalakshmi   35.00   2.00   1.00   19.00   24.00   2.00  

60.00   499555g   ananth   23.00   1.00   1.00   16.00   23.00   2.00  

29.00   496228g   mani  das   29.00   1.00   1.00   64.00   80.00   2.00  

4.00   162060g   mahadeb   28.00   1.00   1.00   17.00   22.00   2.00  

84.00   210517g   raja   19.00   1.00   1.00   29.00   34.00   2.00  

41.00   493056g   tapaskumar   34.00   1.00   1.00   11.00   42.00   2.00  

42.00   486550g   ruksana   42.00   2.00   1.00   8.00   12.00   2.00  

30.00   646229g   uma   37.00   2.00   1.00   16.00   24.00   2.00  

86.00   229949g   nishukumar   18.00   1.00   1.00   17.00   23.00   2.00  

55.00   641936g   sajidansari   28.00   1.00   1.00   18.00   24.00   2.00  

77.00   837965f   madhankumar   19.00   1.00   1.00   31.00   36.00   2.00  

25.00   932933d   baskar   22.00   1.00   1.00   17.00   22.00   2.00  

37.00   626393g   asimkumar   32.00   1.00   1.00   15.00   23.00   2.00  

49.00   322798g   rabindrakumar   21.00   1.00   1.00   56.00   72.00   2.00  

95.00    

khadija   33.00   2.00   1.00   17.00   25.00   2.00  

81.00   093905g   mitakidebnath   24.00   2.00   1.00   6.00   9.00   2.00  

70.00   632312g   khokanbiswas   46.00   1.00   1.00   16.00   22.00   2.00  

45.00   646941g   abdulla   38.00   1.00   1.00   11.00   30.00   3.00  

6.00   250855g   vanaja   61.00   2.00   1.00   15.00   20.00   3.00  

11.00   246669g   imrulkayes   20.00   1.00   1.00   26.00   43.00   3.00  

7.00   414584g   pinturatan   41.00   1.00   1.00   37.00   50.00   3.00  

18.00   399837g   madhumondal   27.00   1.00   1.00   36.00   42.00   3.00  

13.00   444910g   tumpabasu   35.00   2.00   1.00   38.00   56.00   3.00  

15.00   509480a   sathiya   30.00   2.00   1.00   40.00   52.00   3.00  

 

104  

90.00   472180g   nimaijan   57.00   1.00   1.00   16.00   21.00   3.00  

8.00   427469g   tapan  das   31.00   1.00   1.00   9.00   38.00   3.00  

64.00   007677g   ganga   32.00   2.00   1.00   #NULL!   #NULL!   2.00  

88.00   420156g   ashihkumar   35.00   1.00   1.00   17.00   50.00   2.00  

1.00    

bijansaha   28.00   1.00   1.00   40.00   56.00   3.00  

5.00   450278g   sanjaykumar   19.00   1.00   1.00   16.00   31.00   3.00  

9.00   446915g   manjunath   22.00   1.00   1.00   48.00   66.00   3.00  

DIA0   DIA1   DIA3   DIA5   NOA   EXT   ITI   RS   AC  

#NULL!   #NULL!   #NULL!   #NULL!   #NULL!   #NULL!   1.00   2.00  inability  to  introduce  

40.00   55.00   45.00   40.00   1.00   2.00   2.00   2.00   nil  

62.00   72.00   60.00   43.00   1.00   2.00   2.00   2.00   nil  

80.00   90.00   78.00   64.00   2.00   1.00   2.00   2.00   nil  

#NULL!   #NULL!   #NULL!   #NULL!   2.00   #NULL!   1.00   1.00  inability  to  

introduce  scope  

#NULL!   #NULL!   #NULL!   #NULL!   #NULL!   #NULL!   1.00   1.00  could  not  

introduce  scope  

80.00   72.00   70.00   68.00   2.00   2.00   2.00   2.00   nil  

70.00   78.00   60.00   58.00   1.00   2.00   2.00   2.00   nil  

73.00   57.00   57.00   65.00   1.00   2.00   2.00   2.00   nil  

70.00   80.00   60.00   58.00   1.00   1.00   2.00   2.00   nil  

87.00   78.00   78.00   87.00   1.00   2.00   2.00   2.00   nil  

72.00   84.00   60.00   58.00   1.00   1.00   2.00   2.00   nil  

72.00   80.00   68.00   58.00   1.00   2.00   2.00   2.00   nil  

71.00   78.00   76.00   77.00   1.00   1.00   2.00   2.00   nil  

78.00   74.00   68.00   62.00   1.00   2.00   2.00   2.00   nil  

82.00   90.00   72.00   64.00   1.00   2.00   2.00   2.00   nil  

76.00   82.00   64.00   59.00   1.00   1.00   2.00   2.00   nil  

72.00   90.00   70.00   60.00   1.00   1.00   2.00   2.00   nil  

70.00   72.00   62.00   67.00   1.00   2.00   2.00   2.00   nil  

72.00   74.00   74.00   70.00   1.00   2.00   2.00   2.00   nil  

65.00   92.00   91.00   92.00   1.00   2.00   2.00   2.00   nil  

72.00   84.00   62.00   62.00   1.00   2.00   2.00   2.00   nil  

80.00   90.00   90.00   80.00   1.00   2.00   2.00   2.00   nil  

70.00   74.00   70.00   70.00   1.00   2.00   2.00   2.00   nil  

64.00   65.00   67.00   65.00   1.00   2.00   2.00   2.00   nil  

70.00   72.00   60.00   60.00   1.00   1.00   2.00   2.00   nil  

72.00   84.00   78.00   58.00   1.00   1.00   2.00   2.00   nil  

60.00   58.00   54.00   52.00   1.00   1.00   2.00   2.00   nil  

80.00   82.00   87.00   76.00   1.00   2.00   2.00   2.00   nil  

72.00   80.00   70.00   64.00   1.00   2.00   2.00   2.00   nil  

72.00   82.00   65.00   50.00   1.00   2.00   2.00   2.00   nil  

72.00   84.00   62.00   58.00   1.00   2.00   2.00   2.00   nil  

72.00   90.00   60.00   70.00   1.00   1.00   2.00   2.00   nil  

72.00   88.00   70.00   60.00   2.00   1.00   2.00   2.00   nil  

78.00   78.00   78.00   56.00   1.00   2.00   2.00   2.00   nil  

72.00   89.00   58.00   58.00   2.00   2.00   2.00   2.00  difficulty  in  intro  

of  scope  

74.00   87.00   90.00   89.00   1.00   1.00   2.00   2.00   nil  

72.00   90.00   80.00   78.00   1.00   1.00   2.00   2.00   nil  

78.00   85.00   92.00   67.00   1.00   2.00   2.00   2.00   nil  

 

105  

64.00   70.00   62.00   60.00   1.00   2.00   2.00   2.00   nil  

80.00   100.00   80.00   69.00   1.00   2.00   2.00   2.00   nil  

78.00   84.00   82.00   60.00   1.00   2.00   2.00   2.00  lower  lip  

superficial  cut  

72.00   70.00   68.00   62.00   1.00   2.00   2.00   2.00   nil  

70.00   90.00   84.00   60.00   2.00   2.00   2.00   2.00   nil  

90.00   94.00   73.00   84.00   2.00   2.00   2.00   2.00   nil  

96.00   98.00   76.00   62.00   1.00   2.00   2.00   2.00   nil  

90.00   89.00   47.00   48.00   1.00   1.00   1.00   1.00   bronchospasm  

78.00   90.00   87.00   67.00   1.00   1.00   2.00   2.00   nil  

90.00   62.00   64.00   82.00   1.00   2.00   2.00   2.00   no  

60.00   58.00   100.00   90.00   1.00   2.00   #NULL!   2.00   nil  

80.00   80.00   76.00   72.00   1.00   2.00   2.00   2.00   nil  

93.00   628143g   kashinathporia   48.00   1.00   2.00   #NULL!   #NULL!   2.00  

26.00   484134g   pabanchandra   44.00   1.00   2.00   10.00   28.00   2.00  

85.00   331629g   srimoti   30.00   2.00   2.00   3.00   17.00   2.00  

17.00   471503g   manjula   35.00   2.00   2.00   10.00   68.00   2.00  

58.00   498379g   sandeepsingh   28.00   1.00   2.00   14.00   54.00   2.00  

38.00   488837g   kalairasam   21.00   1.00   2.00   6.00   36.00   2.00  

78.00   222522d   soumenkabiraj   24.00   1.00   2.00   12.00   27.00   2.00  

20.00   493130g   rituagarwal   40.00   2.00   2.00   17.00   22.00   2.00  

43.00   242311f   susanta   20.00   1.00   2.00   8.00   54.00   2.00  

62.00   827780b   samundeshwari   35.00   2.00   2.00   8.00   38.00   2.00  

51.00   620159g   abhinay   46.00   1.00   2.00   11.00   24.00   2.00  

44.00   081377g   mdanis   44.00   1.00   2.00   15.00   53.00   2.00  

68.00   339289g   valsama   39.00   2.00   2.00   4.00   11.00   2.00  

67.00   627404g   bijankumar   39.00   1.00   2.00   15.00   30.00   2.00  

63.00   766467f   shib  das   18.00   1.00   2.00   10.00   19.00   2.00  

52.00   628285g   rahulkumar   18.00   1.00   2.00   7.00   22.00   2.00  

65.00   499102g   sobhachowdhury   19.00   2.00   2.00   9.00   21.00   2.00  

72.00   427453g   sumitrasasmal   54.00   2.00   2.00   5.00   67.00   2.00  

40.00   641883g   jaffar   32.00   1.00   2.00   8.00   25.00   2.00  

21.00   656269g   pamparoy   32.00   2.00   2.00   7.00   21.00   2.00  

15.00   769637d   hemnath   22.00   1.00   2.00   7.00   37.00   2.00  

22.00   070798c   shabber   18.00   1.00   2.00   18.00   35.00   2.00  

98.00   612734g   ramprasad   23.00   1.00   2.00   19.00   64.00   2.00  

89.00   326855b   muniamal   52.00   2.00   2.00   4.00   28.00   3.00  

76.00   181914g   mdabdullah   19.00   1.00   2.00   7.00   17.00   3.00  

3.00   415391g   rajeevkumar   26.00   1.00   2.00   18.00   40.00   3.00  

91.00   840299c   alamelu   40.00   2.00   2.00   7.00   18.00   3.00  

35.00   621523g   akramhussain   64.00   1.00   2.00   6.00   36.00   3.00  

27.00   478695g   safiya   54.00   2.00   2.00   9.00   42.00   3.00  

2.00   621566d   palash  das   32.00   1.00   2.00   20.00   58.00   3.00  

59.00   270706f   fazalullah   52.00   1.00   2.00   10.00   23.00   3.00  

48.00   446739g   sumanamunian   25.00   2.00   2.00   33.00   68.00   3.00  

32.00    

purnimaya   35.00   2.00   2.00   13.00   19.00   3.00  

28.00   604005g   madhusudan   29.00   1.00   2.00   17.00   35.00   3.00  

33.00   482809g   syedmoshiyur   35.00   1.00   2.00   12.00   25.00   3.00  

 

106  

54.00   199241f   ramesh   29.00   1.00   2.00   9.00   42.00   3.00  

14.00   532436d   pratima   42.00   2.00   2.00   28.00   72.00   3.00  

87.00   163609d   dhanalakshmi   32.00   2.00   2.00   5.00   12.00   3.00  

66.00   637616f   smritisaha   37.00   2.00   2.00   12.00   22.00   1.00  

96.00   067704f   jayakanthi   34.00   2.00   2.00   14.00   52.00   2.00  

82.00   474885g   rikupanigrhi   37.00   2.00   2.00   19.00   27.00   2.00  

80.00   631292g   sumathi   33.00   2.00   2.00   35.00   55.00   2.00  

57.00   635658g   mohammedomar   45.00   1.00   2.00   19.00   36.00   2.00  

73.00   300187g   bantisingh   38.00   1.00   2.00   10.00   22.00   2.00  

100.00   156204f   kumar   37.00   1.00   2.00   14.00   38.00   2.00  

39.00   112078g   valarmathi   40.00   2.00   2.00   9.00   29.00   3.00  

10.00   654386d   nirmala  s   31.00   2.00   2.00   70.00   103.00   3.00  

12.00   452196b   chanmahamadali   50.00   1.00   2.00   16.00   76.00   3.00  

#NULL!   #NULL!   #NULL!   #NULL!   #NULL!   #NULL!   #NULL!   #NULL!   #NULL!  

#NULL!   73.00   70.00   64.00   62.00   120.00   107.00   103.00   100.00  

22.80   110.00   100.00   89.00   98.00   113.00   122.00   98.00   109.00  

25.00   72.00   68.00   64.00   69.00   133.00   112.00   85.00   95.00  

24.50   75.00   72.00   69.00   63.00   95.00   140.00   89.00   85.00  

17.00   82.00   80.00   66.00   65.00   118.00   106.00   104.00   90.00  

20.00   84.00   85.00   88.00   93.00   107.00   126.00   113.00   115.00  

23.60   84.00   86.00   72.00   74.00   110.00   116.00   92.00   98.00  

21.70   68.00   72.00   66.00   64.00   128.00   127.00   110.00   114.00  

21.40   81.00   85.00   88.00   85.00   96.00   99.00   102.00   90.00  

24.50   68.00   74.00   68.00   70.00   120.00   126.00   110.00   110.00  

21.20   68.00   74.00   68.00   70.00   132.00   128.00   110.00   108.00  

24.10   82.00   90.00   87.00   88.00   108.00   107.00   112.00   98.00  

23.80   92.00   100.00   84.00   80.00   110.00   120.00   92.00   88.00  

17.30   76.00   85.00   97.00   103.00   85.00   139.00   103.00   98.00  

18.20   80.00   90.00   92.00   84.00   110.00   120.00   110.00   100.00  

17.00   100.00   110.00   90.00   86.00   100.00   110.00   98.00   88.00  

22.90   78.00   89.00   81.00   81.00   141.00   142.00   140.00   130.00  

22.30   68.00   80.00   74.00   78.00   110.00   122.00   108.00   110.00  

19.30   72.00   84.00   68.00   70.00   120.00   128.00   110.00   112.00  

25.00   110.00   124.00   108.00   110.00   128.00   130.00   100.00   110.00  

21.60   72.00   88.00   86.00   72.00   110.00   128.00   110.00   108.00  

21.60   84.00   105.00   82.00   76.00   151.00   160.00   144.00   122.00  

23.00   96.00   92.00   96.00   87.00   150.00   159.00   151.00   87.00  

21.10   68.00   67.00   66.00   80.00   120.00   126.00   103.00   110.00  

25.00   66.00   66.00   61.00   61.00   90.00   87.00   89.00   88.00  

19.20   54.00   56.00   57.00   62.00   166.00   97.00   102.00   89.00  

22.70   80.00   84.00   79.00   83.00   108.00   122.00   116.00   113.00  

23.50   99.00   103.00   101.00   92.00   124.00   130.00   141.00   106.00  

22.00   64.00   74.00   86.00   80.00   120.00   98.00   132.00   124.00  

24.20   77.00   87.00   84.00   90.00   112.00   119.00   109.00   98.00  

24.70   88.00   98.00   88.00   83.00   112.00   108.00   108.00   100.00  

22.30   63.00   77.00   75.00   76.00   140.00   130.00   117.00   102.00  

23.40   73.00   87.00   75.00   86.00   122.00   135.00   127.00   134.00  

 

107  

24.40   68.00   87.00   89.00   65.00   111.00   145.00   130.00   105.00  

23.60   87.00   108.00   97.00   85.00   95.00   134.00   126.00   106.00  

21.50   84.00   106.00   100.00   100.00   110.00   150.00   140.00   126.00  

22.60   85.00   122.00   97.00   88.00   118.00   141.00   120.00   108.00  

28.50   100.00   96.00   90.00   70.00   140.00   120.00   124.00   110.00  

26.60   102.00   96.00   110.00   98.00   132.00   140.00   112.00   98.00  

28.20   110.00   112.00   106.00   100.00   132.00   136.00   109.00   97.00  

29.90   126.00   128.00   110.00   98.00   122.00   132.00   108.00   96.00  

27.40   75.00   81.00   80.00   76.00   100.00   105.00   110.00   108.00  

28.10   72.00   84.00   80.00   68.00   112.00   122.00   114.00   123.00  

28.00   77.00   91.00   86.00   85.00   122.00   142.00   118.00   101.00  

29.00   97.00   96.00   88.00   82.00   148.00   123.00   92.00   89.00  

26.00   79.00   100.00   92.00   80.00   106.00   139.00   127.00   100.00  

26.00   60.00   84.00   72.00   66.00   140.00   148.00   130.00   120.00  

                 BMIR   totalR   time_diff   HR_diff1   HR_diff1_cat  

#NULL!   #NULL!   #NULL!   #NULL!   #NULL!  

#NULL!   1.00   5.00   -­‐3.00   2.00  

#NULL!   1.00   5.00   5.00   2.00  

#NULL!   2.00   12.00   16.00   1.00  

1.00   #NULL!   #NULL!   #NULL!   #NULL!  

1.00   #NULL!   #NULL!   #NULL!   #NULL!  

1.00   2.00   4.00   -­‐16.00   2.00  

1.00   1.00   12.00   -­‐6.00   2.00  

1.00   1.00   12.00   -­‐2.00   2.00  

1.00   2.00   19.00   -­‐2.00   2.00  

1.00   1.00   6.00   2.00   2.00  

1.00   2.00   11.00   4.00   2.00  

1.00   1.00   8.00   4.00   2.00  

1.00   2.00   9.00   5.00   2.00  

1.00   1.00   5.00   5.00   2.00  

1.00   1.00   7.00   6.00   2.00  

1.00   2.00   14.00   6.00   2.00  

1.00   2.00   13.00   6.00   2.00  

1.00   1.00   7.00   7.00   2.00  

1.00   1.00   8.00   8.00   2.00  

1.00   1.00   5.00   8.00   2.00  

1.00   1.00   7.00   8.00   2.00  

1.00   2.00   16.00   9.00   2.00  

1.00   1.00   5.00   10.00   1.00  

1.00   1.00   5.00   10.00   1.00  

1.00   2.00   31.00   10.00   1.00  

1.00   2.00   4.00   10.00   1.00  

1.00   2.00   8.00   10.00   1.00  

1.00   1.00   6.00   12.00   1.00  

1.00   1.00   6.00   12.00   1.00  

1.00   1.00   5.00   12.00   1.00  

 

108  

1.00   1.00   5.00   12.00   1.00  

1.00   2.00   8.00   14.00   1.00  

1.00   2.00   16.00   16.00   1.00  

1.00   1.00   8.00   18.00   1.00  

1.00   2.00   3.00   26.00   1.00  

1.00   2.00   6.00   30.00   1.00  

1.00   2.00   19.00   -­‐2.00   2.00  

1.00   2.00   5.00   1.00   2.00  

1.00   1.00   17.00   2.00   2.00  

1.00   2.00   13.00   9.00   2.00  

1.00   1.00   6.00   10.00   1.00  

1.00   1.00   18.00   10.00   1.00  

1.00   2.00   12.00   18.00   1.00  

1.00   2.00   5.00   24.00   1.00  

1.00   1.00   29.00   25.00   1.00  

2.00   #NULL!   #NULL!   36.00   1.00  

2.00   2.00   33.00   38.00   1.00  

2.00   1.00   16.00   -­‐18.00   2.00  

2.00   1.00   15.00   -­‐6.00   2.00  

2.00   1.00   18.00   20.00   1.00  

#NULL!   #NULL!   #NULL!   #NULL!   #NULL!  

#NULL!   2.00   18.00   -­‐3.00   2.00  

1.00   2.00   14.00   -­‐10.00   2.00  

1.00   2.00   58.00   -­‐4.00   2.00  

1.00   2.00   40.00   -­‐3.00   2.00  

1.00   1.00   30.00   -­‐2.00   2.00  

1.00   1.00   15.00   1.00   2.00  

1.00   1.00   5.00   2.00   2.00  

1.00   2.00   46.00   4.00   2.00  

1.00   2.00   30.00   4.00   2.00  

1.00   2.00   13.00   6.00   2.00  

1.00   2.00   38.00   6.00   2.00  

1.00   1.00   7.00   8.00   2.00  

1.00   2.00   15.00   8.00   2.00  

1.00   2.00   9.00   9.00   2.00  

1.00   1.00   15.00   10.00   1.00  

1.00   2.00   12.00   10.00   1.00  

1.00   2.00   62.00   11.00   1.00  

1.00   2.00   17.00   12.00   1.00  

1.00   2.00   14.00   12.00   1.00  

1.00   2.00   30.00   14.00   1.00  

1.00   2.00   17.00   16.00   1.00  

1.00   2.00   45.00   21.00   1.00  

1.00   2.00   24.00   -­‐4.00   2.00  

1.00   2.00   10.00   -­‐1.00   2.00  

1.00   2.00   22.00   0.00   2.00  

1.00   2.00   11.00   2.00   2.00  

 

109  

1.00   1.00   30.00   4.00   2.00  

1.00   2.00   33.00   4.00   2.00  

1.00   2.00   38.00   10.00   1.00  

1.00   1.00   13.00   10.00   1.00  

1.00   2.00   35.00   10.00   1.00  

1.00   2.00   6.00   14.00   1.00  

1.00   2.00   18.00   14.00   1.00  

1.00   1.00   13.00   19.00   1.00  

1.00   2.00   33.00   21.00   1.00  

1.00   2.00   44.00   22.00   1.00  

1.00   #NULL!   7.00   37.00   1.00  

2.00   1.00   10.00   -­‐4.00   2.00  

2.00   2.00   38.00   -­‐6.00   2.00  

2.00   2.00   8.00   2.00   2.00  

2.00   2.00   20.00   2.00   2.00  

2.00   2.00   17.00   6.00   2.00  

2.00   2.00   12.00   12.00   1.00  

2.00   2.00   24.00   14.00   1.00  

2.00   1.00   20.00   -­‐1.00   2.00  

2.00   2.00   33.00   21.00   1.00  

2.00   2.00   60.00   24.00   1.00