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    cormack lehane modificada por cook

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    © All Rights Reserved
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    23 views6 pages

    Cook 2000

    Uploaded by

    Manuel Villasana
    cormack lehane modificada por cook

    Copyright:

    © All Rights Reserved
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    Foran plama-catecholamine response du to endotracheal tubation. Journal of Clinial Anethesie 1997; 9: 143-7 16 Ghignone N, Quintin L, Duke PC, Kehler CH, Calle (©. Bfect of clonidine on narcoie requirement nd hhemodysumie response daring induction of fentanyl anesthesia and endotracheal intubation. Anitheilegy 1986 64: 36-12, 17 Osko R, Pourtu J, Ghighone M, Rosenberg PH. Bieet of clonidine on haemodynamic responses to endotracheal intubation and gastrie acidity Acta Anaesthesia candnavica 987, 81: 325-9, 18 Mikawa K, Mackawa N, Nishina K, Takao Y, Yau 3, (Obara H. Lifciey of orl clonidine premedication in cullen, Anetheolegy 1993; 79: 926-31 19 Byzd I BE Collins W, Primm K. Risk factons for severe bradycardia during oil clonidine therapy for hypertension, Anhiver of Internal Medine 1988; 148: 729-33, 20 Favre JB, Gardaz JPP, Ravussn P. Effect of clonidine on ICP and on the Bemodynamic response to nociceptive sims in patiente with rain tamors Journal of Newosgery sand Anesthesislgy 1995; 78: 159-67, 21 Ghingone M, Cavilo ©, Quinsin L. Anesthesia and FORUM Aresiesi, 200,55, 260-287 Inypertenson: the effect of clonidine on perioperative hemodynamics and isoflurane requirements, Anetheioigy 1987; 67: 3-10, 22 Filo KS, Patroni O, Goudas LC, Bosar ©, Ksteaat A, Garaginis S.A dose-response sudy of orally adm clonidine st premedication in the eldedy: erating Ihemodynamie safety. Anita and Analgesia 1993; 77: 1185-92, 25 Wright PMC, Catabine UA, McClane S, Orr DA, Moore J. Presnesthetic medietion with clonidine, British Journal of Anssthia 1990; 65: 525-32 24 Guglclminots J, Descragues C, Petitmaire S, Almenaa L Grenapin ©, Mant J. Effect of premedication on dave requirement for propofol: comparivon of clonidine and Inydtoxyzine, British Journal of Ancesthesia 1998; 80: 733-6. 25 Kobinger W, Pichler L. Locabzston in the CNS of adrenoceptors which fsiitate a cardiinhibitory reflex [Naunyn Sdamiedebegs Archive of Pharmacology 1975; 286: sn-T 26 Civero I, Roach AG. Efect of clonidine on canine carise neuroefictor structures contolling heatt rte. Bish Journal of Pharmaslgy 1980; 70: 269-76, ered A new practical classification of laryngeal view Summary Bat 3NG, UK ‘A new practical clasification of laryngeal view at laryngoscopy is presented and evaluated. The best laryngeal view obtained with or without anterior laryngeal pressure is recorded, The laryngeal view is eary (E) when the laryngeal inlet is visible. The view is restriaed (R) when the posterior glotic structures (posterior commissure oF arytenoids) are visible or the epiglottis is visble and can be lifted; thie includes some grade 2 and some grade 3 views as classified by Cormack and Lehane. A dificult (D) views ie present when the epiglottis cannot be lifted or when no laryngeal structures are visible. Five hundred patients were studied. Laryngoscopy, with the patient anaesthetized and paralysed, wae performed with a Macintosh laryngoscope. If the vocal cords were not visible, a ‘gum elastic bougie war used to aid intubation, Other aide were used only if this did not allow intubation. Each laryngeal view war graded according to the new clasfication and that of ‘Cormack and Lehane, Intubation was timed and the equipment needed to facilitate intubation was recorded, The new classification stratified increasing difficulty with intubation (time for intubation longer and increasingly complex methods needed) better than the Cormack and Lehane chssification, The new classification i as sensitive and more specific than the Cornyack and Lehane chssification in predicting difficult intubation. It is also more sensitive and more 9% predicting easy intubation, 278 1 2000 ual cece id Aanaertes, 200, $5, 260-287 Keywords Intubation, laryngeal dificuty. Conespondence a: Dr T M. Cook Auceped: § Oxcber 1999 ‘Most anaesthetists will attempt to use information fom previous anaesthetic records to determine whether tra- cheal intubation mighe prove difficult [1]. Cormack and Lehane [2] described 2 classification of the laryngeal view during laryngoscopy. The clasification was described 0 allow simulated dificult intubation, Ie has been widely adopted and ie used by most anaesthetists but is applied inaccurately by the majority [1]. There have been attempts to amend the clasification [3, 4] to improve its sensitivity in delineating increasing dificulty with intubation. Yentis ly evaltated a modification in which grade 2 was divided into 2s and 2b [1]. This paper presente a new clasfication of laryngeal view which aims to match grade ‘of view with degree of difficulty and with the practical technique needed to achieve intubation, The elasifc: is evaluated and compared with Cormack and Lehane’. Method ‘The new classification (Fig, 1) records the best laryngeal view obtained with or without anterior laryngeal pressure. ‘The view is easy (E) when the laryngeal inlet is visible ‘These views are suitable for intubation under direct vision, The view is restricted (R) when the posterior glotic structures (posterior commissure oF arytenoid cartilages) are visible or the epiglottis ie visble and can be lifted ‘These views are likely to benefit from indirect method: (eg. gum clastic bougie). A dificult (D) view is present shen the epiglotts cannot be lifted oF when no laryngeal Hructures are viable, These views are likely to need specialist methods for intubation which may need to be pexformed blindly, Forum In order to explain the new clasification and compare it with that of Cormack and Lehane’s, it is necessary to subdivide their grade 2 and grade 3 views. Grade 2 views in which part of the vocal cords ean be seen are grade 23 ‘Those in which the vocal cords cannot be seen are grade 2b. Grade 3 views in which the epiglottis can be seen and lifted, for instance with a gum clastic bougie, are grade 5a, ‘When this cannot be done they are grade 3b, Table 1 compares the new and old clasification. The ‘asy () view inchudes all grade 1 views and easier grade 2 views (28). Rested (R) views include some grade 2 (2b) and some grade 3 views (3). Difficult (D) view includes the ‘more dificult grade 3 (3b) and all grade 4 ‘The study was discussed with the chaitmtan of the Local ‘Research and Ethies Committee: patent consent was not required as clinical practice was not altered by inclusion in ‘the study, Five hundeed consecutive patients requiring oral ‘wacheal intubation for elective surgery were studied. Incubation was performed by myself in all cases. Patients were excluded if an awake fibzeoptic technique was used. Six months ofthe study period was devoted to neurosurgi- cal anaesthesia and inchuded patients with severe cervical spine pathology presenting for cervical surgery. A farther 44 months of the study took place in 2 hospital with a high proportion of patients with theumatoid arthritis, present= ing similar problems. Several cases identified by colleagues 1 difficult to intubste were studied, After induction of anaesthesia, muscular paralysis was provided with stxamethonium or a nondepolarsing muscle relaxant in the dose recommended in the data chest, Laryngoscopy was performed with the Macintosh no. 3 Dlade either Lmin after administeation of suxamethonivm nA $e oro 2 ore 25 se ove eae ore 20 es Onvoe Raw Bae Beas Cw SEY SSE wer’ a ae ar Figure 1 Cormack and Lehane casifeation and new clasifeation of view at lryngorcopy. 28 Foran Anaesth, 2000, $5, 260-287 Table 1 Clasifeation oflryngeal grade: Cormack and Lchane's and new clsifistion Most of cords visbe 1} Direct Ont aytenoids visible 2 2b ’ nesrncres. tooo nl an al ; z] het Tur Epiglostc adherent o phar 2 sb} No laryngeal structures seen ay Spedatin pirricutr for 3min afer nondepolarising relaxant. A gum elstic Dougie war always available and was used immediately where the vocal cords could not be seen, as recommended by Nolan [5], Other aids were used ifintubation could not be achieved with the standard blade and gum elsstic Dougie after thrce attempts. Aids included a long Macin- tosh blade, MeCoy blade, laryngeal mask airway and stylet. A fibrcoptic laryngoscope was available but not necessarily in the operating theau cases. The intubating. laryngeal mask became availsble midway through the dy. The best view of the larynx was obtained with carefal hhead and neck positioning, correct laryngoscopy tech- nique and anterior laryngeal pressure if not gride 1. Laryngeal view was recorded according Cormack and Lehane’ clasification including subdivie sions and the new classification, Duration of laryngoscopy ‘as timed from the anaestherist being handled the laryngo- scope to the time the tracheal tube passed through the vocal cords, Aids needed for intubation, including gum chstic bougie, were recorded Tracheal intubation was considered easy when it was pesformed within 30s without a gum clastic bougie or additional intubation aids and difficult where intubation took longer than 4 min or required aids in addition to the ‘gum clastic bougie The two laryngeal view cli sions were compared other aide s No.) ed n) ttearer 500 106 5 grade 1 334.668) 3 ° grade 2 163 288) ” ° grade 3 26) a 6 Easy an aa 2 ° Restrced 780538) % ° bitte 318) 3 5 276 to determine their ability to detect easy and dificult int bation ensitivity and positive predictive value) and their ability to exclude false postuves (specificity) Differences in time to intubate between groups were determined with Kraskal—Wallis one-way aNova, Inter group differences were then contrasted with Mann— Whitney testing, Comparisons between categorical data were performed with Chi-squared or Fisher exact test as appropriate. Statistical analysis was performed with Analyse-it statistical package (Analyse-it Software Led, Leeds, UK) and Microsoft Excel 97. A p value of less than 0105 was taken to indicate statistical significance Results Distribution of laryngeal grade and ease of intubation are recorded in Tables 2 and 3, There were 287 female and 213 male patients. Median (range) age was 51 (16~91) yeats and mean (SD) weight was 74 (16) ke, All 300 patients were successfully sntubated, The gum chatic bougie was used in 106 cases (21%), Other airway aajunets were used on six occasions (1.2%), in five of which difficulty with intubation was anticipated: features included small jaw and reduced mouth opening, sheuma- toid arthritis of the neck and poor dentition, cervical ‘myelopathy, neck in ‘halo’ traction and previous known dificult intubation, Four of there patients refuse awake Table 2 Laryngesl view and intubation duals, Cormack and Lehane’ and new chssifeason Intubation times) median (ange) 146-1500) 126-48) 228-66) 5215-1500) 3366-50) s2(-186) «20 (84-1800) Aanaertes, 200, $5, 260-287 Table 3 Laryngeal view and intabation deus: Subdivisions of grades 2 and $ ; rade 23 grade 25 grade 3a Forum Intubation times) Other aide Wo. (8) wed in) used median Vangel 0 106 . 1416-1500) 78.58) 8 ° 168-50) 53) 6 ° 31 (ieee) Maa) 4 ° 3515-180) a8) ° . 420 (96-1500) Sloreoptic intubation. The MeCoy laryngoscope was wed fon four occasions and did not facilitate intubation, The Jong Macintosh blade was used on four oceasions without hhelping. The intubating laryngeal mask was wed four times and was successful on three, In two patients, fibseoptic intubation was performed asleep after other techniques failed. One patient was intubated using a gum ehstic Dougie via a laryngeal mask airway. ‘The median intubation time was 145 with range of 615005 (median without bougie 13s, with bougie 323) A oul of 397 patients (79.496) were intubated within 30 ‘without gum clatic bougie or other adjuncts (eay intuba- sion). Filfy-nine patients (11.8%) took longer than 305 to intubate. There were seven difficult intubations (1.494) — six needed adjuncts in addition to the gum elastic bougie and all these took longer than 4 min to intubate. Time to intubate difered significantly between groups (© <0.0001, anova). There were statistically significant dlferences between grade 1 and 2, 2 and 3, ewy (B) and resriaed (R) and between retriced (R) and dificult (D) (© <0.0001, Mann-Whitney test; Fig, 2). Time to into bate abo differed significantly between grades 2a and 2. 32 and 3b (p-<0.0001), There was no significant differ- tence between grades 2b and 3a (p= 0.18). (Table 4) ‘The wse of aids to intubation (excluding gum elastic bougic) differed significantly between grades 2 and 3, Reatited and Difilt, and grades 3a and 3b (Psher exact test p< 0.0001, p<0.0001 and p < 0.001, respectively) 1600 + I sal 1200 | a ol =i ey Time (s) 1 = 2a 2 3a Grade + 3b Figure 2 ‘Time taken to intubste according to grade of laryngeal view. Range (=) and median (9, Grades 3 and 4 laryngeal view predicted dlicult incubation with sensitivity of 100%, specificity of 96.7% and positive predictive vale of 30.4%. Difical laryngeal view predicted dificult intubation with sensitivity of 100%, specificity of 99.6% and positive predictive value of 77%. Difficult view was significantly more specific and Inada higher predictive value at predicting difficult intuba- tion than grades 3 and 4 (Fisher exact test p=0.001 and p=004, respectively) Grade 1 laryngeal view predicted cay intubation with seosiivity 80.3%, specificity of 87.3% and positive pre- dictive value of 95.594, When grades 1 and 2 were com- sy of 100%, specificity of 22.3% and positive predictive value of 83.2%. Euy laryngeal view predicted eas intubation with bined, easy intubation was predicted with sens sensitivity 96.2%, specificity of 70.1% and positive pre- dictive value of 92.7%. Thus Easy view is significandly: ‘moze sensitive than grade 1 view st predicting easy intubation (Fisher exact test p < 0.0001), athe cost of a small zeduetion in specificity and positive predictive value, Compared with grades 1 and 2, eay view is less sensitive (@<0.001, but moze specific (p<0.0001) and with Detter postive predictive value (p < 0.0001), Discussion Ikis in the nature of suadies requiring visual asessment that observer bias may be introduced. In devising a new clisification and evaluating it myself, it is possible that iy observations are biated or that the cussfcation i only. Table 4 Time taken for inmubstion, Comparisons between rides: Mann-Whitney texts pales Grades compared twa “<9.001 aw oe davedb 00001 dowd 018 every 8.0001 sy vs Rested -

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