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   Table of Contents - Current issue
Coverpage
September-December 2019
Volume 2 | Issue 3
Page Nos. 107-164

Online since Thursday, January 30, 2020

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EDITORIAL  

What's new in the diagnosis and management of obstructive sleep apnoea? p. 107
Rahul Magazine
DOI:10.4103/ARWY.ARWY_2_20  
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REVIEW ARTICLE Top

Oral appliances in the management of obstructive sleep apnoea syndrome p. 109
Puppala Ravindar, Kethineni Balaji, Kanamarlapudi Venkata Saikiran, Ambati Srilekha, Kondapaneni Alekhya
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.
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SPECIAL ARTICLE Top

Descriptive statistics: Measures of central tendency, dispersion, correlation and regression p. 120
Zulfiqar Ali, S Bala Bhaskar, K Sudheesh
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.
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ORIGINAL ARTICLES Top

Clinical techniques to prevent cough at emergence from general anaesthesia: A meta-analysis p. 126
Alex Joseph, Rajkumar Rajendram
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.
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Anaesthesiologists' role in diagnostic drug-induced sleep endoscopy and subsequent management strategy planning in obstructive sleep apnoea syndrome p. 135
Amodini Kukreja, Anshul Shenkar, K Sathish, Nalini Kotekar
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.
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Addition of optics to laryngoscope design improves success of intubation: A prospective, observational study p. 142
Vaishali Chandrashekhar Shelgaonkar, Piyush Arvind Dhawad, Medha Akhilesh Sangawar
DOI:10.4103/ARWY.ARWY_20_19  
Background: Many novel intubating videoscopes such as the GlideScope, McGrath®, Truview EVO2® videolaryngoscope (VLS), Airtraq® and C-MAC® VLS have been introduced in the recent past in an attempt to reduce airway-related morbidity and mortality. In this study, we aimed to compare the ease and success of intubation using Airtraq, Truview VLS and McCoy blade laryngoscope in non-difficult airway situations. Patients and Methods: Ninety patients with clinically normal airways belonging to American Society of Anesthesiologists Physical Status I–II were randomly assigned to be intubated using Airtraq (Group AL; n = 30), Truview VLS (Group TL; n = 30) or McCoy (Group ML; n = 30). The primary outcome measures were Intubation Difficulty Scale score and time for successful intubation. Assessment of modified Cormack–Lehane (MCL) grade at laryngoscopy, Percentage of Glottic Opening (POGO) score, haemodynamic variations, any optimisation manoeuvre required during endotracheal intubation, ease of intubation score and complications were the secondary outcomes. Results: The time for successful intubation was statistically significantly less with Airtraq as compared with both ML and Truview VLS (P < 0.05). Intubation Difficulty Score improved significantly with Airtraq and Truview VLS when compared with that of McCoy blade. Airtraq and Truview significantly improved MCL grading, POGO score and ease of intubation score. These devices also required less optimisation manoeuvres (P < 0.05) and had less haemodynamic variations although not statistically significant (P > 0.05). Conclusion: We conclude that both the Airtraq and Truview VLS are devices whose optical design improves intubating conditions in patients with non-difficult airways.
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CASE REPORTS Top

Persistent buccopharyngeal membrane: Anaesthetic management p. 148
Reena , Shweta Agarwal, Kanika Gupta, Pradeepika Gangwar
DOI:10.4103/ARWY.ARWY_21_19  
Persistent buccopharyngeal membrane (PBM) is a rare congenital anomaly. Very few case reports have been published to date. We report the case of a 5-year-old girl with PBM with a central 1 cm diameter perforation posted for excision of the membrane. We have briefly reviewed the embryology of PBM with a focus on perioperative anaesthetic concerns and airway management options.
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Fibreoptic intubation in an adult with restricted mouth opening facilitated by improvised bite block from the barrel of syringe p. 151
Prem Raj Singh, Tanmay Tiwari, Vaibhav Tewari, Gyan Prakash Singh
DOI:10.4103/ARWY.ARWY_22_19  
Fibreoptic intubation is an effective technique for establishing airway access in patients with both anticipated and unanticipated difficult airways. First described in the late 1960s, this approach can facilitate airway management in a variety of clinical scenarios given proper patient preparation and technique. In anticipated difficult airway, the preferred choice of airway management is awake fibreoptic bronchoscopy (FOB), which requires ample amount of expertise and experience. We present a case of difficult airway with extremely restricted mouth opening which was managed by using the barrel of a syringe as an added guide for FOB.
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Innovative use of fibreoptic bronchoscope as a flexible, manoeuvrable stylet during C-MAC videolaryngoscopy p. 154
Suresh Govindswamy, Balakrishna Shenoy, Sharmila Rajamohan, Priya Mitali
DOI:10.4103/ARWY.ARWY_28_19  
The C-MAC videolaryngoscope has been used along with bougies, pliable metal stylet and optical stylet during the management of the difficult airway. The fibreoptic bronchoscope (FOB) was used as a last resort in our patient to direct the endotracheal tube into the trachea. A 74-year-old male (American Society of Anesthesiologists Physical Status III) who had undergone cervical spine instrumentation 12 years prior was scheduled for laparoscopic prostatectomy. On examination, he was found to have restricted neck movements. In view of the anticipated difficult airway, awake fibreoptic intubation was planned, for which the patient did not give consent. A FOB with a preloaded endotracheal tube was used as a flexible stylet. The fibrescope was manoeuvred towards the glottis which was visualised with the help of the C-MAC videolaryngoscope, resulting in successful intubation.
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Interventional bronchoscopy for tracheal tumours: An anaesthetic challenge p. 157
Jyoti Sharma, Prashant Kumar, Shweta Bhardwaj, Sumit Das
DOI:10.4103/ARWY.ARWY_30_19  
Tracheal tumours may present with potentially catastrophic airway obstruction. There are many challenges in the management of anaesthesia for obstructing intratracheal tumours by rigid bronchoscopy, such as difficulty in ventilation, securing airway, sharing of airway with the surgeon and control of seepage of blood and tumour tissues distally into the tracheobronchial tree during resection. We report a 58-year-old woman, known case of renal cell carcinoma for whom right nephrectomy was done, who presented with sudden respiratory distress. Computed tomography showed a polypoidal lesion measuring 8 mm anteroposteriorly and 9 mm transversely in the trachea with attachment at the 6 o'clock position just before the tracheal bifurcation obstructing 70%–80% of the lumen. The tumour was resected through a rigid bronchoscope using electrocautery and a polypectomy snare. Careful preoperative evaluation of the site and degree of obstruction, on-going communication between surgeon and anaesthesiologist, tailored anaesthetic management techniques and meticulous postoperative care can help to deal with the difficulties and complications associated with the management of these cases.
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Lessons learnt from a difficult intubation scenario: Videolaryngoscopes cannot replace the humble bougie p. 161
Chandni Maheshwari, Divya Kavita
DOI:10.4103/ARWY.ARWY_29_19  
With the advent of videolaryngoscopes, the incidence of difficult intubation has decreased. Videolaryngoscopes are slowly replacing other airway gadgets such as the fibreoptic bronchoscope and intubating supraglottic devices, especially in institutions where they are freely available. These could not only be the first choice in anticipated difficult intubation but also the first rescue device in unanticipated difficult intubations. A failed intubation can occur despite obtaining a good view of the glottis with a videolaryngoscope. We were unable to intubate an anticipated difficult airway with C-MAC D-blade with a preformed hockey stick-shaped tube using a stylet despite using manoeuvres to optimise laryngeal view. The patient was finally intubated over a gum elastic bougie passed when retaining the videolaryngoscope in place. This case report highlights that a simple gum elastic bougie holds an equally important place on the difficult airway cart as a videolaryngoscope. The use of a gum elastic bougie should be considered as important as a videolaryngoscope in a difficult intubation scenario. It is reasonable to attempt the use of a bougie in the case of failed videolaryngoscope-assisted intubation before switching to another intubating device or a supraglottic airway. A dental consult for poor dentition should be taken prior to surgery whenever possible. Control of bleeding from a broken tooth needs to be done simultaneously and expeditiously even when we have visualised the glottis and are anticipating a successful intubation.
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