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   Table of Contents - Current issue
Coverpage
May-August 2019
Volume 2 | Issue 2
Page Nos. 55-105

Online since Wednesday, August 28, 2019

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EDITORIAL  

Airway assessment by ultrasonography: Is it the final answer? p. 55
Arindam Choudhury, Rohan Magoon
DOI:10.4103/ARWY.ARWY_26_19  
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REVIEW ARTICLE Top

Voice loss following endotracheal intubation: The anaesthesiologist's dilemma p. 57
Nalini Kotekar, Sriram Vyshnavi
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.
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SPECIAL ARTICLE Top

Describing and displaying numerical and categorical data p. 64
Sudheesh Kannan, Pradeep A Dongare, Rakesh Garg, SS Harsoor
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.
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ORIGINAL ARTICLES Top

Correlation between ultrasonographic evaluation of the airway and Cormack-Lehane view by direct laryngoscopy in the Indian subpopulation p. 71
Gagan Kumar Narula, Abdul Nasser
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.
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Does prewarming of tracheal tubes prevent epistaxis following nasotracheal intubation? A prospective, randomised, single-blind study p. 77
Anuja Agrawal, Bhavika Sangada, Dinesh Chauhan, Tejash Sharma
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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Comparative performance of I-gel and laryngeal mask airway supreme: A randomised, controlled study p. 81
B Uma, Uttam Chand Verma, Rajesh Singh Rautela, Anjali Kochhar
DOI:10.4103/ARWY.ARWY_16_19  
Patients and Methods: In a randomised, controlled study, we compared the performance of i-gel against the laryngeal mask airway (LMA) Supreme in 60 anaesthetised and paralysed patients for non-laparoscopic surgical procedures. Results: The primary outcome measure, the oropharyngeal leak pressure (OLP), was significantly higher for i-gel as compared to LMA Supreme (mean [standard deviation] 26.23 [4.09] vs 21.73 [3.19] cm H2O, respectively; P < 0.0001). Twenty-four (80%) of LMA Supreme and 22 (73.3%) of i-gels were successfully placed with similar ease on the first attempt to achieve an effective airway. The time taken for inserting the LMA Supreme was significantly less than that required for i-gel (mean [SD] 7.89 [1.6] s vs 11.48 [4.86] s, respectively; P < 0.0001). Gastric tube insertion was easier in the LMA Supreme as compared to i-gel (96.7% vs 63.3% respectively; P < 0.0001). There were no differences in the positioning of the supraglottic airway devices as evaluated fibreoptically. Postoperative sore throat was comparable with both devices. Conclusion: We conclude that while both these devices are suitable for routine use during maintenance of anaesthesia, a significantly higher OLP might provide the i-gel an advantage in this respect.
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CASE REPORTS Top

Airway management following assessment by virtual bronchoscopy subsequent to failed intubation in a child with tetralogy of Fallot p. 89
Mayuri Golhar, Tarun Yadav, Mangal Singh Ahalawat, Prashant Kumar, Samsher Singh Lochab
DOI:10.4103/ARWY.ARWY_17_19  
Children with congenital anomaly have a higher incidence of a difficult airway. Routine airway assessments have their limitations due to low sensitivity for predicting airway difficulties. We report the successful airway management of a 10-year-old girl with tetralogy of Fallot who had a history of failed intubation. Virtual bronchoscopy revealed subglottic narrowing. Careful planning on the basis of virtual bronchoscopy findings leads to a successful perioperative course. We recommend that virtual bronchoscopy be used as an airway assessment tool in anticipated difficult airway.
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Dynamic ultrasound assessment of airway: A novel approach in a patient with goitre p. 93
Debendra Kumar Tripathy, Bhavna Gupta, Anup G Patil, Atif Khan
DOI:10.4103/ARWY.ARWY_9_19  
A 31-year-old female with bilateral neck swelling causing tracheal narrowing and deviation of trachea to the left side was posted for total thyroidectomy. Long standing thyroid swellings with or without associated airway compromise are a challenge for anaesthesiologists to secure the airway. Because of the thyroid swelling, there may be deviation of trachea and/or compression of the trachea. Here we present a case of long-standing goitre with tracheal deviation and compression of trachea at the level of 2nd tracheal ring. Securing the airway in such cases poses a great challenge requiring meticulous planning and skillful experience. Careful preoperative evaluation and preparation in the form of clinical and radiological assessment is essential in formulating a plan of anaesthesia. Though static assessment is always important and helps in deciding the plan of management, conventional parameters may not be true in all cases such as in ours. Dynamic assessment may help the anaesthesiologist in deciding airway management in such cases.
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Difficult airway caused by retained iron rod penetrating through floor of mouth and base of tongue following road traffic accident: A case report p. 96
Tanmay Tiwari, Anshu Singh, Jyoti Rawat, Jyothi Chaudhary
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.
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Pilot tube misadventure during submental intubation - A new twist to the story! p. 100
Khaja Mohideen Sherfudeen, Ramu Ganesan, Senthil Kumar Kaliannan, RP Ravichandran
DOI:10.4103/ARWY.ARWY_18_19  
The technique of submental intubation provides a secure airway and an unobstructed surgical field for adequate reduction and fixation of panfacial fractures. Procedural complications during submental intubation such as surgical difficulty, bleeding, flexometallic tube damage, migration of flexometallic tube, obstruction of flexometallic tube are well known. We faced a new problem during submental intubation because of the pilot tube which formed a loop inside the submental tunnel.
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Anaesthetic management of a patient with difficult airway for T-tube insertion p. 103
Bhavna Gupta, Bharti Wadhwa, Prachi Gaba, Kirti Nath Saxena
DOI:10.4103/ARWY.ARWY_15_19  
A 60-year-old male, case of benign oesophageal stricture and unresectable carcinoma bucco-alveolar mucosa had suffered tracheal injury during oesophagectomy for refractory oesophageal stricture. Tracheal repair was done with rectus sheath graft over tracheostomy tube and he was now posted for T-tube insertion. There are various techniques reported for this procedure. Anaesthesiologists should be aware of surgical technique, limitations of T-tube, loss of depth of anaesthesia during tube change, and should be vigilant during all the steps of the procedure. We used total intravenous anaesthesia (TIVA) as a technique with propofol and dexmedetomidine for providing safe and effective anaesthesia during this procedure. Perioperative period was uneventful.
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