RACTICE Guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. In addition, Practice Guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice Guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open-forum commentary, and clinical feasibility data. This document updates the “Practice Guidelines for Management of the Difficult Airway: An Updated Report by

practice Guidelines for Management of the Difficult airway An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway

Introduction: The Glidescope video laryngoscope has been shown to be a useful tool to improve laryngeal view. However, its role in the daily routine of airway management remains poorly characterized. Methods: This investigation evaluated the use of the Glidescope at two academic medical centers. Electronic records from 71,570 intubations were reviewed, and 2,004 cases were indentified where the Glidescope was used for airway management. WeanalyzedthesuccessrateofGlidescopeintubationinvarious intubationscenarios.Inaddition,theincidenceandcharacterof complications associated with Glidescope use were recorded. PredictorsofGlidescopeintubationfailureweredeterminedus

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Routine clinical practice effectiveness of the Glidescope in difficult airway management: an analysis of 2,004 Glidescope intubations, complications, and failures from two institutions.

Background
Successful tracheal intubation during general anaesthesia traditionally requires a line of sight to the larynx attained by positioning the head and neck and using a laryngoscope to retract the tongue and soft tissues of the floor of the mouth. Difficulties with intubation commonly arise, and alternative laryngoscopes that use digital and/or fibreoptic technology have been designed to improve visibility when airway difficulty is predicted or encountered. Among these devices, a rigid videolaryngoscope (VLS) uses a blade to retract the soft tissues and transmits a lighted video image to a screen.

Objectives
Our primary objective was to assess whether use of videolaryngoscopy for tracheal intubation in adults requiring general anaesthesia reduces risks of complications and failure compared with direct laryngoscopy. Our secondary aim was to assess the benefits and risks of these devices in selected population groups, such as adults with obesity and those with a known or predicted difficult airway.

Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase on 10 February 2015. Our search terms were relevant to the review question and were not limited by outcomes. We carried out clinical trials register searches and forward and backward citation tracking. We reran the search on 12 January 2016; we added potential new studies of interest from the 2016 search to a list of 'Studies awaiting classification', and we will incorporate these studies into the formal review during the review update.

Selection criteria
We considered all randomized controlled trials and quasi-randomized studies with adult patients undergoing laryngoscopy performed with a VLS or a Macintosh laryngoscope in a clinical, emergency or out-of-hospital setting. We included parallel and cross-over study designs.

Data collection and analysis
Two review authors independently assessed trial quality and extracted data, consulting a third review author to resolve disagreements. We used standard Cochrane methodological procedures, including assessment of risk of bias.

Main results
We included 64 studies identified during the 2015 search that enrolled 7044 adult participants and compared a VLS of one or more designs with a Macintosh laryngoscope. We identified 38 studies awaiting classification and seven ongoing studies. Of the 64 included studies, 61 included elective surgical patients, and three were conducted in an emergency setting. Among 48 studies that included participants without a predicted difficult airway, 15 used techniques to simulate a difficult airway. Seven recruited participants with a known or predicted difficult airway, and the remaining studies did not specify or included both predicted and not predicted difficult airways. Only two studies specifically recruited obese participants. It was not possible to blind the intubator to the device, and we noted a high level of inevitable heterogeneity, given the large number of studies.

Statistically significantly fewer failed intubations were reported when a VLS was used (Mantel-Haenszel (M-H) odds ratio (OR), random-effects 0.35, 95% confidence Interval (CI) 0.19 to 0.65; 38 studies; 4127 participants), and fewer failed intubations occurred when a VLS was used in participants with an anticipated difficult airway (M-H OR, random-effects 0.28, 95% CI 0.15 to 0.55; six studies; 830 participants). We graded the quality of this evidence as moderate on the basis of the GRADE system. Failed intubations were fewer when a VLS was used in participants with a simulated difficult airway (M-H OR, random-effects 0.18, 95% CI 0.04 to 0.77; nine studies; 810 participants), but groups with no predicted difficult airway provided no significant results (M-H OR, random-effects 0.61, 95% CI 0.22 to 1.67; 19 studies; 1743 participants).

Eight studies reported on hypoxia, and only three of these described any events; results showed no differences between devices for this outcome (M-H OR, random-effects 0.39, 95% CI 0.10 to 1.44; 1319 participants). Similarly, few studies reported on mortality, noting no differences between devices (M-H OR, fixed-effect 1.09, 95% CI 0.65 to 1.82; two studies; 663 participants), and only one study reporting on the occurrence of respiratory complications (78 participants); we graded these three outcomes as very low quality owing to lack of data. We found no statistically significant differences between devices in the proportion of successful first attempts (M-H OR, random-effects 1.27, 95% CI 0.77 to 2.09; 36 studies; 4731 participants) nor in those needing more than one attempt. We graded the quality of this evidence as moderate. Studies reported no statistically significant differences in the incidence of sore throat in the postanaesthesia care unit (PACU) (M-H OR, random-effects 1.00 (95% CI 0.73 to 1.38); 10 studies; 1548 participants) nor at 24 hours postoperatively (M-H OR random-effects 0.54, 95% CI 0.27 to 1.07; eight studies; 844 participants); we graded the quality of this evidence as moderate. Data combined to include studies of cross-over design revealed statistically significantly fewer laryngeal or airway traumas (M-H OR, random-effects 0.68, 95% CI 0.48 to 0.96; 29 studies; 3110 participants) and fewer incidences of postoperative hoarseness (M-H OR, fixed-effect 0.57, 95% CI 0.36 to 0.88; six studies; 527 participants) when a VLS was used. A greater number of laryngoscopies performed with a VLS achieved a view of most of the glottis (M-H OR, random-effects 6.77, 95% CI 4.17 to 10.98; 22 studies; 2240 participants), fewer laryngoscopies performed with a VLS achieved no view of the glottis (M-H OR, random-effects 0.18, 95% CI 0.13 to 0.27; 22 studies; 2240 participants) and the VLS was easier to use (M-H OR, random-effects 7.13, 95% CI 3.12 to 16.31; seven studies; 568 participants).

Although a large number of studies reported time required for tracheal intubation (55 studies; 6249 participants), we did not present an effects estimate for this outcome owing to the extremely high level of statistical heterogeneity (I2 = 96%).

Authors' conclusions
Videolaryngoscopes may reduce the number of failed intubations, particularly among patients presenting with a difficult airway. They improve the glottic view and may reduce laryngeal/airway trauma. Currently, no evidence indicates that use of a VLS reduces the number of intubation attempts or the incidence of hypoxia or respiratory complications, and no evidence indicates that use of a VLS affects time required for intubation.

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Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation

Introduction
The Glidescope® video-laryngoscopy appears to provide better glottic visualization than direct laryngoscopy. However, it remains unclear if it translates into increased success with intubation.

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Glidescope® video-laryngoscopy versus direct laryngoscopy for endotracheal intubation: a systematic review and meta-analysis

The aim of the present paper is to review the literature regarding video-laryngoscopes (Storz V-Mac and C-Mac, Glidescope, McGrath, Pentax-Airway Scope, Airtraq and Bullard) and discuss their clinical role in airway management. Video-laryngoscopes are new intubation devices, which provide an indirect view of the upper airway. In difficult airway management, they improve Cormack-Lehane grade and achieve the same or a higher intubation success rate in less time, compared with direct laryngoscopes. Despite the very good visualization of the glottis, the insertion and advancement of the endotracheal tube with video-laryngoscopes may occasionally fail. Each particular device's features may offer advantages or disadvantages, depending on the situation the anaesthesiologist has to deal with. So far, there is inconclusive evidence indicating that video-laryngoscopy should replace direct laryngoscopy in patients with normal or difficult airways.

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Video-laryngoscopes in the adult airway management: a topical review of the literature

Background The purpose of this study was to determine the potential for the Pentax AWS® and the Glidescope® to reduce the difficulty of tracheal intubation in patients at increased risk for difficult tracheal intubation, in a randomized, controlled clinical trial. Methods Seventy-five consenting patients presenting for surgery requiring tracheal intubation, and who were deemed to possess characteristics indicating an increased risk for difficult tracheal intubation, were randomly assigned to undergo intubation using a Macintosh, AWS®, or Glidescope® laryngoscope (n=25 patients per group). All patients were intubated by one of three anaesthetists experienced in the use of each laryngoscope. Results Both the Glidescope® and the AWS® significantly reduced the intubation difficulty score compared with the Macintosh. The rate of successful tracheal intubation was lower with the Macintosh (84%) compared with the Glidescope® (96%) or the AWS® (100%). There were no differences in the duration of tracheal intubation attempts between the devices. Both the Glidescope® and the AWS® significantly reduced the need for additional manoeuvres and improved the Cormack and Lehane view obtained at laryngoscopy, compared with the Macintosh. Tracheal intubation with the AWS® but not the Glidescope® reduced the degree of haemodynamic stimulation compared with the Macintosh laryngoscope. Conclusions The AWS® and the Glidescope® laryngoscopes reduced the difficulty of tracheal intubation to a similar extent compared with the Macintosh laryngoscope, in patients at increased risk for difficult tracheal intubation.

Randomized controlled trial of the Pentax AWS®, Glidescope®, and Macintosh laryngoscopes in predicted difficult intubation

Background The purpose of this study was to evaluate the effectiveness of the Pentax AWS®, and the LMA CTrach®, in comparison with the Macintosh laryngoscope, when performing tracheal intubation in patients with neck immobilization using manual in-line axial cervical spine stabilization. Methods Ninety patients undergoing anaesthesia who required tracheal intubation were randomly assigned to undergo intubation using a Macintosh (n=30), LMA CTrach® (n=30), or AWS® (n=30) laryngoscope. All patients were intubated by one of the three anaesthetists familiar with the use of each laryngoscope. Results The intubation difficulty scores were significantly higher with the Macintosh laryngoscope and were significantly lower with the AWS® compared with the LMA CTrach. All 30 patients were successfully intubated with the Macintosh and the AWS® device, compared with 27 patients with the LMA CTrach®. The duration of both the first and the successful tracheal intubation attempts was significantly longer with the LMA CTrach® compared with the AWS® and Macintosh laryngoscopes. A greater number of optimization manoeuvres were required to facilitate tracheal intubation with the LMA CTrach® compared with the AWS® laryngoscope. The AWS® group had a significantly better Cormack and Lehane glottic view obtained at laryngoscopy compared with both other devices. Conclusions The AWS® laryngoscope has several advantages over the Macintosh laryngoscope, or LMA CTrach®, in patients undergoing cervical spine immobilization.

Tracheal intubation in patients with cervical spine immobilization: a comparison of the Airwayscope®, LMA CTrach®, and the Macintosh laryngoscopes

Background. The purpose of this study was to evaluate the effectiveness of the Pentax AWS w , and the LMA CTrach w , in comparison with the Macintosh laryngoscope, when performing tracheal intubation in patients with neck immobilization using manual in-line axial cervical spine stabilization. Methods. Ninety patients undergoing anaesthesia who required tracheal intubation were randomly assigned to undergo intubation using a Macintosh (n¼30), LMA CTrach w (n¼30), or AWS w (n¼30) laryngoscope. All patients were intubated by one of the three anaesthetists familiar with the use of each laryngoscope. Results. The intubation difficulty scores were significantly higher with the Macintosh laryngoscope and were significantly lower with the AWS w compared with the LMA CTrach. All 30 patients were successfully intubated with the Macintosh and the AWS w device, compared with 27 patients with the LMA CTrach w . The duration of both the first and the successful tracheal intubation attempts was significantly longer with the LMA CTrach w compared with the AWS w and Macintosh laryngoscopes. A greater number of optimization manoeuvres were required to facilitate tracheal intubation with the LMA CTrach w compared with the AWS w laryngoscope. The AWS w group had a significantly better Cormack and Lehane glottic view obtained at laryngoscopy compared with both other devices. Conclusions. The AWS w laryngoscope has several advantages over the Macintosh laryngoscope, or LMA CTrach w , in patients undergoing cervical spine immobilization.

CRITICAL CARE Tracheal intubation in patients with cervical spine immobilization: a comparison of the Airwayscope w , LMA CTrach w , and the Macintosh laryngoscopes


 
 
 Posterior Urethral Valves (PUV) are the most common cause of bladder outlet obstruction in male infants. Despite definitive management by endoscopic valve resection, some patients develop persistent bladder dysfunction and progressive chronic kidney disease (CKD). This study aims to evaluate the long-term complications of PUV, as well as evaluate bladder and renal dysfunction pre- and post-operatively.
 
 
 
 A retrospective review of all the patients who received PUV ablation between 2012 to 2016 in a tertiary paediatric urology centre. Data collected included demographics, laboratory and radiographic investigations, and surgical outcomes. The data were analysed with SPSS.
 
 
 
 Twenty-three patients were included in the study; antenatal diagnosis was made in 43.5% (n=10) with 56.5% (n=13) postnatally. Mean follow-up time was 7.1±2.3 years (4.8–9.4). Voiding dysfunction was the most common complication in later life (34.8%, n=8), followed by CKD (13.0%, n=3), kidney transplant (8.7%, n=2), hypertension (8.7%, n=2) and mortality (8.7%, n=2).
 There was a statistically significant difference (p=0.003) between pre- and post-operative creatinine values. 5 patients who had creatinine values postoperatively of >88.4μmol/L (21.7%) sustained poor renal outcomes.
 Radiologically, there was a significant improvement in the anteroposterior (AP) diameter of the renal pelvis and kidney growth based on current, post-operative and preoperative ultrasound (p<0.05). Nevertheless, there was no statistically significant improvement in ureteric dilatation.
 
 
 
 Post PUV ablation, urinary incontinence and CKD remain the most substantial long-term outcome. Proactive multidisciplinary management with careful follow-up are essential to reduce the burden of the disease.


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R. Subramaniam

Papers

Randomized controlled trial of the Pentax AWS®, Glidescope®, and Macintosh laryngoscopes in predicted difficult intubation

Tracheal intubation in patients with cervical spine immobilization: a comparison of the Airwayscope®, LMA CTrach®, and the Macintosh laryngoscopes

CRITICAL CARE Tracheal intubation in patients with cervical spine immobilization: a comparison of the Airwayscope w , LMA CTrach w , and the Macintosh laryngoscopes

274 Retrospective Cohort Study of the Long-Term Outcome of Posterior Urethral Valve – A Single Centre Experience