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  Most popular articles (Since July 10, 2018)

 
 
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REVIEW ARTICLE
Voice loss following endotracheal intubation: The anaesthesiologist's dilemma
Nalini Kotekar, Sriram Vyshnavi
May-August 2019, 2(2):57-63
DOI:10.4103/ARWY.ARWY_25_19  
Endotracheal intubation is a routine procedure performed by anaesthesiologists worldwide. It is as routine as the placement of a peripheral intravenous catheter. Albeit the gold standard for securing the airway, endotracheal intubation comes with it's share of adverse effects, one of the worst being loss of voice or aphonia. A literature search in major medical databases revealed useful information about the aetiopathogenesis, various mechanisms and risk factors leading to vocal symptoms and acoustic variations. Patient risk factors such as age and co-morbid conditions and anaesthetic considerations such as size of endotracheal tube, number of attempts, mean cuff pressure, anaesthetic agents used and nature and duration of surgery all seem to have a role in this intriguing problem. This review also includes cases we have personally come across in our practice. Based on our experience of cases that we have come across, we propose an algorithm to avoid such a problem.
  24,506 729 4
SPECIAL ARTICLE
Descriptive statistics: Measures of central tendency, dispersion, correlation and regression
Zulfiqar Ali, S Bala Bhaskar, K Sudheesh
September-December 2019, 2(3):120-125
DOI:10.4103/ARWY.ARWY_37_19  
Large data obtained from research are subjected to statistical analysis so that outcomes can be extrapolated to the larger population. Towards this end, such large data have to be consolidated into smaller, simpler expressions of measures, representing the outcomes of the whole sample. These form the descriptive statistics, which will later on help in inferential statistics, involving the different variables within one group and more than one group. Their distribution features are analysed and are described as sums, averages, relationships and differences. These measures are classified as those of central location and those of dispersion. Mean, Median and Mode are the three main measures of central tendency and Range. Percentile, variance, standard deviation, standard error and confidence interval are measures of dispersion. Correlation and regression can be used to describe the relationship between two numerical variables. Correlation is a measure of association and regression is used for prediction. Regression analysis helps to assess 'influential' relationships between the data. Changes among one or more variables might affect other variables.
  16,982 788 1
Describing and displaying numerical and categorical data
Sudheesh Kannan, Pradeep A Dongare, Rakesh Garg, SS Harsoor
May-August 2019, 2(2):64-70
DOI:10.4103/ARWY.ARWY_24_19  
The set of observations recorded during research work is termed data. Data can be described as numerical or categorical. While numerical data are further divided into discrete or continuous, categorical data are further divided into nominal or ordinal data. These data may be represented in a textual manner or with the help of illustrations (tables or graphs). The selection of a proper mode of representation of data helps in the optimal understanding of results. The level of importance of each parameter determines the mode of representation. The present article attempts to introduce the various methods of data presentation and throw some light on the benefits and limitations of each mode of data presentation.
  8,503 441 1
REVIEW ARTICLE
Ultrasound imaging of the airway and its applications
Anusha Cherian, Pankaj Kundra
September-December 2018, 1(1):17-24
DOI:10.4103/ARWY.ARWY_12_18  
Airway ultrasound (US) provides a dynamic assessment of the airway. In conjunction with other imaging techniques such as computerised tomographic (CT) scan and magnetic resonance imaging (MRI), ultrasonography of the airway can influence airway management decisions. There is some evidence to support its use in the prediction of difficult airway by measuring pre-tracheal soft-tissue thickness and pre-epiglottis space thickness. However, the dynamic scan of vocal cord movements may replace direct visualisation techniques in the future. In addition, measurements of the subglottic diameter by US have been shown to predict endotracheal tube size as accurately as MRI or CT scan. US-assisted or US-guided front of the neck procedures such as percutaneous dilatational tracheostomy is safer and more accurate with decreased rate of complications. Localisation of cricothyroid membrane with US in difficult necks may become a life-saving procedure when complete ventilation failure is encountered. The use of US to overcome airway challenges is growing at a rapid pace adding newer dimensions to its use.
  7,675 1,196 -
REVIEW ARTICLES
Patient positioning and glottic visualisation: A narrative review
V R Hemanth Kumar, Nandhakumar Janani, Maurya Indubala, Velraj Jaya
January-April 2020, 3(1):13-18
DOI:10.4103/ARWY.ARWY_3_20  
Optimal glottic view is a prerequisite for successful endotracheal intubation. Several factors such as height of pillow, head position, backup position and head-elevated laryngoscopy position (HELP) have been attributed to improve glottic view. This review of existing literature was conducted to summarise current evidence on the influence of different head positions on glottic view. The search engines used were PubMed, Cochrane Library, Google Scholar and ResearchGate. Keywords used for the search were sniffing position, HELP, backup position and glottic view. The two components of optimal sniffing position used traditionally for laryngoscopy include neck flexion of 35° and face-plane extension of 15° which is supposed to align three axes (oral, pharyngeal and laryngeal axes). Optimal height of pillow used to achieve sniffing position was found to be 9 cm. Since it is difficult to align all the three axes, the two-curve theory was proposed. Advantage of the sniffing position was questioned by various authors who projected the HELP and 25° backup position as better options. Our narrative review suggests that 25° backup and HELP position improves glottic view in comparison to supine sniffing position. To achieve alignment of external auditory meatus to the sternal notch, a small child required a small pillow, an older child or an adult required a bigger pillow and obese patients needed the ramped position/25° head-up position.
  7,938 499 -
CASE REPORTS
Difficult airway caused by retained iron rod penetrating through floor of mouth and base of tongue following road traffic accident: A case report
Tanmay Tiwari, Anshu Singh, Jyoti Rawat, Jyothi Chaudhary
May-August 2019, 2(2):96-99
DOI:10.4103/ARWY.ARWY_19_19  
Irrational driving among youth is a matter of serious concern in the present world. India leads the way having one of the highest numbers of road traffic accidents (RTAs) globally. Penetrating injury of the face following RTA can be catastrophic due to the close vicinity of vital structures and major blood vessels. Management of airway is of foremost importance for the successful resuscitation of the trauma patient as per the Advanced Trauma Life Support guidelines. We report a case of successful nasal intubation and subsequent anaesthetic management following sedation with ketamine and dexmedetomidine of a young male with penetrating injury of the floor of mouth and base of tongue by an iron rod. Such a combination of ketamine and dexmedetomidine can be an attractive option for airway management in acute trauma settings.
  6,396 249 2
REVIEW ARTICLES
High-flow nasal cannula: A narrative review of current uses and evidence
Wan Jane Liew, Prit Anand Singh
May-August 2020, 3(2):66-75
DOI:10.4103/ARWY.ARWY_21_20  
High-flow nasal cannula (HFNC) is a relatively new mode of oxygen supplementation. Warmed and humidified air/oxygen mixtures are delivered at high flows via a nasal cannula to patients. There are many observed physiological benefits for the use of HFNC. There is, therefore, increasing interest surrounding the use of HFNC in adult patients for improving oxygenation. This highly versatile device has been studied expansively in different clinical scenarios, from critical care, to the operating theatre, and even in palliative care. The usefulness of HFNC in management of the global pandemic of coronavirus disease 2019 further attests to its potential. However, evidence surrounding HFNC is still largely inconclusive. More high-quality randomised studies should be conducted to evaluate and justify the routine use of HFNC. Research efforts focused on developing clinical strategies on initiation, monitoring, escalation, de-escalation and titration will contribute to developing more precise guidelines for HFNC therapy.
  5,708 619 -
ORIGINAL ARTICLES
Clinical techniques to prevent cough at emergence from general anaesthesia: A meta-analysis
Alex Joseph, Rajkumar Rajendram
September-December 2019, 2(3):126-134
DOI:10.4103/ARWY.ARWY_31_19  
Brief summary: Various techniques can reduce the incidence of cough at tracheal extubation. Whilst effect size differs between treatments, homogeneity was identified within each subgroup of treatments. This meta-analysis allows anaesthesiologists to make informed choices on the use of techniques to prevent emergence cough. Background: Cough at extubation increases the risk of morbidity following surgical procedures. So, prevention of cough may aid perioperative risk management. Several techniques have been described for prevention of cough at or immediately after tracheal extubation. This meta-analysis compares various pharmacological methods for prevention of cough at emergence from general anaesthesia and aims to establish an evidence base for the rational use of these techniques. Methods: Several electronic databases (1966-2018) were searched systematically for randomised controlled trials that reported the incidence of cough at extubation. The quality of the studies identified was assessed using the Jadad methodology. Six techniques to prevent cough were analysed using the Mantel-Haenszel fixed-effects model. The odds ratio (OR) and number needed to treat (NNT) were used as the summary efficacy measures. Results: Of 1114 articles screened, 22 comparisons in 17 studies (1007 patients) were included in the final analysis. Significant heterogeneity of effect was observed when all studies were analysed together. However, there was homogeneity within each treatment subgroup. This reflected significant effect-size differences between techniques. The largest effect-sizes were seen with endotracheal tube cuff inflation with alkalinised lignocaine (pooled OR 0.052; 95% CI 0.027-0.102; NNT 1.67) and topical lignocaine (pooled OR 0.065; 95% CI 0.015-0.274; NNT 2.35). Conclusion: The incidence of cough at extubation of the trachea can be reduced. The overall effect size of the studied strategies was useful (pooled OR 0.149; 95% CI 0.13-0.18; NNT 2.62). No single technique prevented cough in all patients but cuff inflation with alkalinised lignocaine and topical 4% lignocaine were most effective.
  5,548 453 -
Comparison of channelled blade with non-channelled Blade of King Vision™ videolaryngoscope for orotracheal intubation: A randomised, controlled, multicentric study
Amit Shah, Apeksh Patwa, Vijitha Burra, Deepshikha Shah, Bhavin Gandhi
January-April 2019, 2(1):10-16
DOI:10.4103/ARWY.ARWY_8_19  
Introduction: We conducted a randomised, controlled, prospective, multicentric comparison of channelled blade versus non-channelled blade of the King Vision™ videolaryngoscope for orotracheal intubation. Patients and Methods: A total of 66 patients included in the study were divided into two groups as follows: Group CH for intubation with channelled blade and Group NC for intubation with non-channelled blade. We compared the intubation time, ease of intubation and best laryngeal view obtained. Ease of intubation was categorised into ease of device insertion and ease of passage of endotracheal tube. Various impingements which occurred at the laryngeal inlet were observed and manoeuvres used to accomplish intubation were noted. Results: The grade of laryngeal exposure and time of laryngeal exposure were similar in both types of blade. We found a shorter intubation time of 15.24 ± 10.6 s in Group CH, whereas it was 28.57 ± 14.09 s in Group NC (P < 0.001). Impingement of the endotracheal tube at the glottic inlet was similar in both the groups, but manoeuvring of the device was not needed after laryngeal exposure in the case of the non-channelled blade. Manoeuvres needed to accomplish successful intubation were different in each group. Intubation with channelled blade requires anticlockwise rotation of the endotracheal tube as it is advanced in the slot while slight withdrawal and redirection towards the centre was needed most often with the non-channelled type of blade. Conclusions: We conclude that when used with the channelled blade, the King Vision videolaryngoscope requires shorter intubation time as compared to its use with the non-channelled blade. Anticlockwise rotation of the advancing endotracheal tube within the channel slot overcomes major impingement at the larynx and facilitates intubation with the use of channelled blade while slight withdrawal and redirection towards the centre are needed for successful intubation using the non-channelled blade.
  5,028 442 2
REVIEW ARTICLE
Oral appliances in the management of obstructive sleep apnoea syndrome
Puppala Ravindar, Kethineni Balaji, Kanamarlapudi Venkata Saikiran, Ambati Srilekha, Kondapaneni Alekhya
September-December 2019, 2(3):109-119
DOI:10.4103/ARWY.ARWY_34_19  
Obstructive sleep apnoea (OSA) is a term used to describe repetitive episodes of complete or partial upper airway obstruction that occur during sleep. It is a highly prevalent medical disorder and a challenge to treat. The treatment options include continuous positive airway pressure, oral appliances and surgical interventions depending on the severity of the condition. Among these, oral appliances are commonly used as primary therapy for the treatment of OSA because these appliances are designed to either encourage maxillary transverse development or advance the mandible, which will significantly reduce the OSA. This narrative review emphasises the role of various oral appliances in the treatment of OSA and will serve as a guide to clinicians in choosing the proper dental appliance.
  5,000 450 2
ORIGINAL ARTICLES
Anaesthesiologists' role in diagnostic drug-induced sleep endoscopy and subsequent management strategy planning in obstructive sleep apnoea syndrome
Amodini Kukreja, Anshul Shenkar, K Sathish, Nalini Kotekar
September-December 2019, 2(3):135-141
DOI:10.4103/ARWY.ARWY_35_19  
Background and Aims: Obstructive sleep apnoea is characterised by repetitive partial or complete obstruction of the upper airway during sleep, leading to the reduction or cessation of airflow despite ongoing respiratory effort. Obesity, dyslipidaemia, hypertension, diabetes mellitus and cardiac arrhythmias are common co-existing comorbidities, placing patients at high risk for anaesthesia should they present for incidental or corrective surgeries. These patients are sensitive to opioids, induction and inhalational anaesthetics. Drug-induced sleep endoscopy (DISE) helps in assessing the exact site of airway obstruction and gives valuable inputs for surgical correction. The procedure includes stage-wise induction of sleep and airway visualisation during pharmacologically-induced sleep. Patients and Methods: Thirty patients, aged between 20 and 60 years, with a history of snoring and night arousals, were selected for DISE after taking informed consent. Intravenous propofol 0.5 mg/kg loading dose, followed by a titrated infusion of up to 50 μg/kg/min, was given throughout the procedure. The lowest value of oxygen saturation (SpO2), apnoeic episodes, total propofol used and DISE findings were documented. The airway was managed after the procedure till the patients regained full consciousness. Results: Lower SpO2 readings were observed in patients with complete collapse at the tongue base and in patients with floppy epiglottis. Conclusion: DISE is a dynamic, safe, easy-to-perform procedure that visualises the precise site of airway obstruction and guides in the planning of surgical correction thereafter. DISE findings provide valuable information for titrating doses of anaesthetic agents for incidental surgeries and perioperative management. However, the fine balance between identifying the obstruction and preventing desaturation is often challenging.
  4,967 481 1
SPECIAL ARTICLE
Types of data, methods of collection, handling and distribution
Umesh Goneppanavar, Zulfiqar Ali, S Bala Bhaskar, Jigeeshu V Divatia
January-April 2019, 2(1):36-40
DOI:10.4103/ARWY.ARWY_11_19  
Statistics is assumed to be a tough nut to crack by novices and young researchers mainly because of the lack of understanding of the fundamentals. This article describes the types of data and the methods for compiling the raw data in an orderly fashion, followed by appropriate handling of the collected data to ensure completeness and quality. Once the data are entered into statistical software, distribution of the data should be assessed to apply appropriate statistical tests. Since the type and nature of distribution of data are the main determinants of the type of statistical test to be applied, researchers should have a thorough understanding of these aspects to help derive meaningful outcome from their research.
  4,597 359 2
REVIEW ARTICLES
Anatomy of infant larynx and cuffed endotracheal tubes
Josef Holzki
January-April 2020, 3(1):4-12
DOI:10.4103/ARWY.ARWY_17_20  
The anatomy of the infant larynx has been discussed since 1897. Mainly, anatomists have described the particulars of the paediatric airway and have laid the base for tube selection for safe intubation of infants. The findings were similar to what anaesthesiologists, paediatric ENT-surgeons and airway endoscopists encountered in daily practice. However, since 2003, radiologists challenged the findings of anatomists, paediatric ENT-surgeons and airway endoscopists by using radiologic modalities (such as computed tomographic scans and magnetic resonance imaging) to propose quite different anatomical forms of the infant larynx. They thought that the outlet of the cricoid ring was oval shaped and that the funnel shape of the larynx had its narrowest part at the glottic level. This can be found neither in endoscopic investigations nor in fresh autopsies, the most realistic approach to the anatomy of the infant larynx. These aspects will be thoroughly discussed in this article.
  4,514 366 -
REVIEW ARTICLE
Teaching and training in airway management: Time to evaluate the current model?
Joanne Spaliaras, Agathe Streiff, Glenn Mann, Tracey Straker
January-April 2019, 2(1):28-35
DOI:10.4103/ARWY.ARWY_12_19  
Management of the airway is central to the practice of anaesthesiology and yet surveys reveal that trainees frequently feel poorly trained in this area. Good skills in airway management include not only technical proficiency with an increasingly complex and wide range of equipment but also the clinical judgement and experience to use them appropriately. Lapses in judgement, education and training are leading causes of patient morbidity and mortality. It is now more imperative than ever for anaesthesiology training programmes to carefully review their curricula and evaluate the educational tools being used for effective advanced airway education of the next generation of airway specialists. Residency programmes have also seen the need to incorporate a formalised airway rotation into their curricula. One to 2-year long airway fellowships are now being advocated to provide the trainee a unique opportunity to master the advanced clinical knowledge and techniques necessary to successfully manage the most challenging clinical scenarios in airway management. It is essential for educators and practitioners alike to consider innovative models of training, advancing and retaining of skills. Such advanced skills can ensure the safe airway management and delivery of quality care to patients of all ages and medical complexity. Before preparation of the manuscript, a PubMed and Cochrane search of the scientific literature published in the past 10 years with the terms 'anesthesiology training', 'airway management education' and 'advanced airway management skills' was conducted.
  4,270 395 4
ORIGINAL ARTICLES
Comparison of the efficacy of lignocaine viscous gargle versus ketamine gargle for the prevention of post-operative sore throat after classic laryngeal mask airway insertion: A prospective randomised trial
Sangeeta Dhanger, Bhavani Vaidiyanathan, Idhuyya Joseph Rajesh, Debendra Kumar Tripathy
September-December 2018, 1(1):13-16
DOI:10.4103/ARWY.ARWY_5_18  
Background and Aims: Post-operative sore throat (POST) after general anaesthesia has been ranked as the eighth most important problem of the current clinical anaesthesiology. In comparison to endotracheal intubation, use of the laryngeal mask airway (LMA) has reduced the incidence of POST but has not been able to completely eliminate it. The aim of this study was to compare the efficacy of viscous lignocaine versus ketamine gargle for the prevention of POST after classic LMA insertion. Patients and Methods: A total of 90 patients scheduled for surgery under general anaesthesia using classic LMA were randomised into two groups of 45 each; Group L (lignocaine) and Group K (ketamine). While patients in Group L received 30 mL of 2% lignocaine viscous gargle 10 min before anaesthesia, patients in Group K received 5% ketamine 1 mL (50 mg) diluted in 29 mL of water. POST was graded at 0, 1, 2, 4, 6, 12, 18 and 24 h after operation on a 4-point scale (0–3). Statistical analysis was done using SPSS software version 16. All data were analysed for normal distribution using the Shapiro–Wilk test, categorical data by the Chi-square test and parametric data by Student's t-test. P < 0.05 was considered to be statistically significant. Results: Incidence as well as the severity of POST was significantly less in the lignocaine group (17.5% mild grade) in comparison to ketamine group (15% moderate grade and 25% mild grade). Conclusion: We conclude that compared to ketamine gargle, 2% lignocaine viscous gargle effectively reduces the incidence as well as the severity of POST following placement of classic LMA.
  4,172 456 -
Correlation between ultrasonographic evaluation of the airway and Cormack-Lehane view by direct laryngoscopy in the Indian subpopulation
Gagan Kumar Narula, Abdul Nasser
May-August 2019, 2(2):71-76
DOI:10.4103/ARWY.ARWY_10_19  
Background: An important aspect of airway management is assessment of the airway to predict difficult intubation. Ultrasonography has recently emerged as a noninvasive tool that is helpful for preoperative airway assessment and management. Patients and Methods: In this study, four sonographic measurements, namely (a) distance of the pre-epiglottic space (PES), (b) distance from epiglottis to the vestibular ligaments' midpoint (EVL), (c) skin to hyoid bone distance (DSHB) and (d) distance from the skin to epiglottis midway between hyoid bone and thyroid cartilage (DSEM) were correlated with the Cormack-Lehane grade obtained by direct laryngoscopy. Results: Of the 77 patients included for data analysis, 19 patients (24% of total) had difficult intubation. Of those with difficult intubation, 63% were female. Pearson's analysis revealed a correlation of Cormack-Lehane grade as weak negative with PES, weak positive with EVL, very weak positive with DSHB and very weak negative with DSEM. To predict difficult airway, the cutoff values for PES, EVL, DSHB and DSEM as determined by the Youden index were found to be 2.8 mm (sensitivity 21.1% and specificity 84.5%), 9.3 mm (sensitivity 36.8% and specificity 86.2%), 12.7 mm (sensitivity 42.1% and specificity 79.3%) and 6.8 mm (sensitivity 21.1% and specificity 87.9%), respectively. The area under the curves of PES, EVL, DSHB and DSEM were all below 0.6. Conclusion: PES, EVL, DSHB and DSEM are poor in predicting difficult intubation. These parameters can, however, be used to rule out difficult intubation because they are all highly specific.
  4,201 413 -
LETTERS TO EDITORS
Crossed-scissor manoeuvre – An underutilised technique of mouth opening for airway management: Boon for out-of-hospital situations
Jyoti Sharma, Prashant Kumar, Satyavir Singhal
May-August 2020, 3(2):100-101
DOI:10.4103/ARWY.ARWY_18_20  
  4,406 148 -
SPECIAL ARTICLE
Study design, errors and sample size calculation in medical research
Sabyasachi Das, Pradeep A Dongare, Umesh Goneppanavar, Rakesh Garg, S Bala Bhaskar
May-August 2020, 3(2):76-84
DOI:10.4103/ARWY.ARWY_29_20  
The choice of an appropriate study design is one of the crucial steps in the research process after framing a research question. A single research question may fit into different study designs. Each design has its own merits and drawbacks; diligence in implementing the methodology and data collection reflects good study design. Sample size justification and power analysis are foundations of a study design. They should ideally be settled when framing a research question and creating the study design. An adequate sample size minimises random error or chance occurrence. 'A just large enough' sample supports the researcher to estimate expected cost, time and feasibility. The sample 'size' is a tug-of-war between reality and scientific effectiveness and is highly influenced by study designs. Null hypothesis (H0) is the assumption that there is no difference in the treatment groups, whereas an assumption that there is a difference is called alternate hypothesis (Ha). Type I error (α) finds difference in the absence of one (false-positive conclusion), whereas Type II error (β) indicates probability of false-negative results. If the calculated P value is smaller than α, the researcher rejects the null hypothesis (H0) and welcomes the alternative hypothesis (Ha). There are several validated software available for sample size calculation. Sample size tends to be smaller for means than percentages. As the sample size increases, the P value tends to become small. Finally, a statistically significant result might not always be clinically relevant.
  4,142 375 1
ORIGINAL ARTICLES
Bedside clinical tests as a screening tool for predicting difficult laryngoscopy and intubation: An observational study
Hemlata V Kamat, Manoj Raju Prabandhankam, Bhumika Pathak, Ajay Phatak
September-December 2018, 1(1):9-12
DOI:10.4103/ARWY.ARWY_6_18  
Context: Morphological characteristics of the airway in a population have regional variations making airway assessment and management a crucial aspect of anaesthesia practice. Aims: (1) To determine the incidence of difficult laryngoscopy and intubation using Cormack–Lehane grading and Intubation Difficulty Scale (IDS). (2) To assess the accuracy of bedside clinical tests in predicting difficult laryngoscopy and intubation. Settings and Design: Prospective observational study was carried out on 200 patients aged 18–70 years, undergoing planned surgical procedures under general anaesthesia requiring endotracheal intubation. Pregnant women, patients with head-and-neck pathology, and patients with trauma were excluded from the study. Patients and Methods: All patients underwent preoperative airway assessment and standard induction procedure. Cormack–Lehane grading was noted during first laryngoscopy and process of intubation evaluated by IDS. Statistical Analysis Used: Descriptive statistics used to depict baseline profile. Chi-square, Student t-test and logistic regression used to determine adjusted effects. Analysis was performed using STATA (14.2). Results: The incidence of difficult laryngoscopy was 15.5% and difficult intubation was 12.5%. Univariate analysis showed body mass index (BMI) >25 kg/m2, neck circumference (NC) >36 cm and modified Mallampati score 3/4 as significant predictors. Logistic regression showed interincisor gap (IIG) (P < 0.001) and NC (P < 0.001) as significant predictors. Conclusions: NC and IIG are rapid, simple bedside tests to predict difficult intubation. Bedside clinical tests have poor discriminative power but still have a role in choosing alternative methods for airway management, making judicious use of time and resources while causing minimum discomfort to the patient.
  4,012 419 -
Comparison of high-flow nasal cannula versus conventional oxygen therapy following extubation after paediatric cardiac surgery
Vijitha Burra, Adalagere Sathyanarayana Lakshmi, Anand V Bhat, V Prabhakar, N Manjunatha
January-April 2019, 2(1):4-9
DOI:10.4103/ARWY.ARWY_2_19  
Background: Respiratory complications after cardiac surgery increase morbidity, mortality and length of hospital stay. Oxygen administered using a high-flow nasal cannula (HFNC) improves oxygenation because of its ease of implementation, tolerance and clinical effectiveness. We sought to compare this technique with conventional oxygen therapy (OT) after extubation following paediatric cardiac surgery. We compared HFNC versus conventional OT in postoperative paediatric cardiac surgical patients. Our primary objective was to evaluate the relative efficiency of improving PaCO2elimination in the first 48 h following extubation. Patients and Methods: A single-centre, prospective, unblinded, randomised controlled trial was conducted in a 15-bedded post-cardiac intensive care unit on 50 paediatric cardiac surgical patients <2 years of age undergoing elective surgery with Risk Adjustment for Congenital Heart Surgery score ≥2. At the start of weaning off ventilation, patients were randomly assigned to either of the following groups: HFNC or OT. Arterial blood samples were collected before and following extubation at the following time points: 1, 6, 12, 24 and 48 h. While the primary outcome was comparison of arterial PaCO2post-extubation, the secondary outcomes were PaO2and PaO2/FIO2 ratios and any complications associated with either technique. Continuous data were expressed as mean ± standard deviation and compared using independent samples t-test or the Mann–Whitney U-test. Chi-square test was used for categorical parameters. Results: Demographic and clinical variables were comparable in the two groups. PaO2and PaO2/FIO2 ratios were significantly improved in the HFNC group (P < 0.05) with lesser requirement of FIO2(P < 0.05) in comparison to conventional OT. No complications were observed during HFNC therapy, nor was there any treatment failure. Conclusion: Compared with conventional OT, the use of HFNC following extubation in paediatric cardiac surgical patients appears to be safe, improves oxygenation and carbon dioxide elimination with lesser inspired oxygen concentration.
  3,951 400 1
Correlation of anticipated difficult airway with concurrent intubation: A prospective observational study
Gayatri Rajeev Sakrikar, Prerana Nirav Shah
January-April 2019, 2(1):22-27
DOI:10.4103/ARWY.ARWY_1_19  
Background: Neither all anticipated difficult airways prove to be difficult intubations nor can all difficult intubations be accurately predicted. We conducted this prospective observational study to evaluate the incidence of anticipated difficult airway and concurrent difficult intubation and look for any correlation between them. Patients and Methods: In this study, 352 patients aged >18 years posted for elective surgery requiring general anaesthesia with the placement of endotracheal tube were recruited after obtaining the Ethical Committee approval and written informed consent. The airway was examined at the time of preanaesthetic check up and assigned the modified Mallampati class and Wilson's score. The modified Mallampati Class III/IV and Wilson's score of >4 were considered a difficult airway. Concurrent intubation was graded according to the Cormack–Lehane classification on laryngoscopy. Other parameters such as the duration of laryngoscopy, time taken for intubation and number of attempts were also noted. The incidence of anticipated and unanticipated difficult airway was calculated separately for each score along with its sensitivity, specificity, positive predictive value and negative predictive value. The significance of this association was analysed using the Chi-square test. Results: The incidence of the anticipated difficult airway by the modified Mallampati classification was 6.8%, whereas that by Wilson's score was 2.5%. The incidence of actual difficult intubation was 13%. Actual difficult airways out of those anticipated by the modified Mallampati classification were only 8, whereas those anticipated by Wilson's score were 27. Correlation between them was calculated using the Chi-square test with P < 0.05 considered as statistically significant. Conclusions: Modified Mallampati classification could fairly predict the true-negative results and Wilson's score even though not routinely used is a better indicator for true-positive values. Thus, Wilson's score should be included in routine preanaesthetic evaluation.
  3,971 363 1
Does prewarming of tracheal tubes prevent epistaxis following nasotracheal intubation? A prospective, randomised, single-blind study
Anuja Agrawal, Bhavika Sangada, Dinesh Chauhan, Tejash Sharma
May-August 2019, 2(2):77-80
DOI:10.4103/ARWY.ARWY_14_19  
Introduction: Nasotracheal intubation has always been considered more traumatic than orotracheal intubation. According to previous studies, warming of endotracheal tubes is a good practice because it softens the tube and increases its flexibility, thereby resulting in less trauma. We aimed to study whether prewarming of nasotracheal tube resulted in less nasal trauma and epistaxis as compared with a tracheal tube at the room temperature. Our primary aim was to evaluate trauma and epistaxis due to nasotracheal intubation. The secondary aim was to observe the grade of epistaxis, ease of nasotracheal intubation, time taken to intubate, number of attempts to intubate and need for Magill's forceps for intubation. Patients and Methods: This prospective, randomised, single-blind study was conducted on 30 participants. Randomisation was done by a concealed envelope method. All participants belonged to the American Society of Anesthesiologists Physical Status I and II. They were allocated to one of two groups (n = 15 in each group). Patients in Group A were intubated with normal nasotracheal tubes at room temperature, while those in Group B were intubated with prewarmed nasotracheal tubes. The tracheal tubes were warmed at 45°C for 60 min. Institutional protocol for general anaesthesia was followed in both groups. Statistical analysis was performed using Medcalc software for Windows version 12.7.5.0. (Belgium). Results: Intubation was significantly easier in Group B (15) compared to Group A (5) (P < 0.0005). Time taken for intubation was significantly shorter in Group B (44.73 ± 11.02 s) as compared to Group A (74.46 ± 21.27 s) (P < 0.0001). The incidence of epistaxis was significantly higher in Group A (9) as compared to Group B (1) (P < 0.005). Conclusion: Incidence of epistaxis following nasotracheal intubation was significantly less with prewarmed tracheal tubes as compared to normal tracheal tubes.
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Role of simulation as a teaching-learning tool for interns
Sarbari Swaika, Siddhartha Chakraborty, Swapnadip Sengupta, Soumitra Mukherjee, Supriyo Choudhury
September-December 2018, 1(1):4-8
DOI:10.4103/ARWY.ARWY_8_18  
Background: Simulation is a realistic representation of real-world dynamics or processes that reflect or parallel patient scenarios. Simulation-based medical education enables knowledge, skills and attitudes to be acquired by all health-care professionals. It has been widely adopted as a training and assessment tool in medical education. The aim of the study was to compare simulation-based versus apprenticeship-based teaching-learning tool on patient. Patients and Methods: In this prospective randomised interventional study, 30 interns were randomly assigned to perform laryngoscopy and endotracheal intubations (L and EI) on patients (Group 1) or on an airway mannequin (Group 2) up to 5 times over 3 successive days. Following this, all interns regardless of their group allocation performed up to 10 intubations on patients. They were assessed and scored by two observers using a rating scale and every attempt scored as 'Success' (1 point) or 'Failure' (0 point). Average scores of intubations of two groups were compared using the paired t-test. Results: Average scores of intubations on 10 patients by two independent observers were 6.220 (standard deviation [SD] 1.1428) in Group 1 and 7.147 (SD 0.6520) in Group 2 and 6.307 (SD 1.1317) in Group 1 and 7.193 (SD 0.6170) in Group 2, respectively (P = 0.012 and 0.014 for Observers A and B, respectively). The score of attempt 1 and attempt 10 was observed by a single observer between groups, and significant difference (P = 0.021) was found at attempt 1 between groups with the mannequin group scoring better. At attempt 10, there was no significant difference between the groups. Conclusion: The mannequin group acquired better skills in airway management with respect to L and EI.
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EDITORIAL
Creating the Indian airway guidelines and beyond
Sheila Nainan Myatra, Venkateswaran Ramkumar
September-December 2018, 1(1):1-3
DOI:10.4103/ARWY.ARWY_15_18  
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ORIGINAL ARTICLES
Is neck roentgenogram essential for airway assessment in thyroid swelling? A 3-year audit in a tertiary care centre
Radhakrishna Shetty Sumalatha, Balaram Chandana, Kandavar Siri
January-April 2019, 2(1):17-21
DOI:10.4103/ARWY.ARWY_7_19  
Introduction: Thyroid swelling leading to airway compromise offers a challenge to the anaesthesiologist. Neck roentgenograms are routinely done as a part of preanaesthetic evaluation in thyroid swellings in our institute. With this audit, we wished to analyse whether routine neck roentgenograms had any role in the airway assessment and management for thyroidectomy. Methodology: After obtaining clearance from the Institutional Ethics Committee, data of all patients who underwent thyroidectomy under general anaesthesia between January 2015 and December 2017 were collected from the Medical Records Department. We collected demographic details along with the details of anaesthetic management of these patients. Our primary objective was to know whether neck roentgenogram was essential in thyroidectomy, and the secondary objective was to analyse the airway management in these patients. Qualitative data were represented as frequencies and percentages and quantitative data as mean and standard deviation. Chi-square test was used to compare the qualitative variables and t-test for quantitative variables, and P < 0.05 was considered statistically significant. Results: A total of 317 thyroidectomies were conducted in our hospital between January 2015 and December 2017. Neck X-ray was done in 275 patients (86.75%), whereas the X-ray was not found or documented in 15 patients (5.45%). X-rays of only 42 patients (16.15%) had positive findings. In 66.7% of the cases with positive finding on neck X-ray, airway was managed with direct laryngoscopy and intubation without any difficulty. Conclusion: We conclude that neck roentgenographs are not a sensitive method for predicting difficult airway in patients with thyroid swelling and could be avoided in routine practice to decrease radiation exposure.
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