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Medicion radiologica de la angulacion cervical comparando la laringoscopia directa con hoja Miller vs. estilete luminoso.

INTRODUCCION

Durante la laringoscopia directa y la intubacion orotraqueal se generan desplazamientos de la lengua y de la epiglotis, asi como extension craneocervical, para posibilitar el alineamiento de los ejes oral, faringeo y laringeo y permitir la visualizacion de la glotis (1). El mantenimiento de una via aerea segura y permeable para garantizar la oxigenacion y prevenir la aspiracion de contenido gastrico es uno de los objetivos principales del tratamiento de los pacientes con lesiones traumaticas u otras enfermedades asociadas a inestabilidad de la columna cervical (2).

Aunque la laringoscopia directa es una tecnica disponible y confiable, su empleo en pacientes con inestabilidad de la columna cervical, aun con proteccion cervical, puede generar extension de esta y aumentar el riesgo de lesiones de la medula espinal (3-7).

No se han realizado estudios con cinefluoroscopia que evaluen el desplazamiento cervical comparando el estilete luminoso con la laringoscopia directa con hojas Miller. Por ello, el objetivo principal del presente estudio fue comparar la motilidad de la columna cervical durante la realizacion de laringoscopia directa utilizando hoja Miller con proteccion cervical, triple maniobra e intubacion con estilete luminoso en pacientes sin predictores de via aerea dificil sometidos a procedimientos de radiologia intervencionista bajo anestesia general.

METODOS

Se realizo un estudio observacional. Serie de casos en la que se incluyo a cinco pacientes, mayores de edad, que firmaron el consentimiento informado, programados para embolizacion de malformacion arteriovenosa cerebral, sin predictores de via aerea dificil. Se excluyo a pacientes en procedimientos de urgencia, con historia de enfermedad coronaria, hipertension arterial, enfermedad pulmonar o trastornos de coagulacion, estomago lleno y antecedente de patologia oral o faringea.

Se incluyo a aquellos pacientes que durante 3 meses cumplieron con los criterios de inclusion y exclusion, y que aceptaron hacer parte del estudio. Con previa obtencion de un acceso venoso y monitoria de signos vitales: electrocardiograma, presion arterial, oximetria de pulso, se hizo la induccion con midazolam 0,01-0,03 mg/Kg, fentanyl 0,5-3,5 mg/Kg, tiopental sodico 2-6 mg/Kg, y se empleo rocuronio 0,6-1 mg/Kg como relajante neuromuscular.

Cuando el paciente se hallo en adecuado plano anestesico, se procedio a obtener una primera imagen fluoroscopica lateral de la columna cervical con la cabeza en posicion neutra (Figura 1a), y manteniendo la ventilacion del paciente con mascara facial: una segunda imagen realizando la triple maniobra (Figura 1b); una tercera imagen realizando la laringoscopia directa con la hoja Miller, hasta obtener una visualizacion de las cuerdas vocales (Figura 1c); una cuarta imagen al visualizar el rombo luminico producto de la transiluminacion con el estilete luminoso (Figura 1d); y una ultima imagen con el paciente intubado con la posicion cefalica que presentaba luego de fijar el tubo (Figura 1e).

Estas imagenes fueron obtenidas por el neurorradiologo en la sala de hemodinamia, con el equipo ANGIOMAT 6000, sistema de inyeccion digital de General Electric que permite obtener imagenes gracias a procesos de sustraccion digital.

Para las mediciones obtenidas se definieron segmentos de movilidad de las vertebras cervicales tomando como limite una linea trazada entre el margen cortical inferior del cuerpo vertebral y el margen inferior de la apofisis espinosa de la vertebra correspondiente. Para tomar los angulos se trazo una linea paralela al eje longitudinal de la mesa de hemodinamia.

[FIGURA 1 OMITIR]

La lectura de las diferentes imagenes, con sus respectivas mediciones y angulaciones en cada uno de los segmentos cervicales, la realizo el neurorradiologo; posteriormente se obtuvieron medidas de tendencia central mediante el uso de estadistica descriptiva.

RESULTADOS

La muestra estudiada corresponde a 5 mujeres, con edades promedio de 43 anos. Se midieron las angulaciones de los segmentos cervicales durante las diferentes posiciones, y estas se encuentran consignadas en la Tabla 1.

En C1 el valor minimo obtenido con laringoscopia fue de 60[grados], y el maximo, de 72[grados]. Para el estilete luminoso el valor minimo obtenido fue de 66[grados], y el maximo, de 82[grados]. En C5 el valor minimo obtenido con laringoscopia fue de 100[grados], y el maximo, de 120[grados]. Para el estilete luminoso el valor minimo obtenido fue de 98[grados], y el maximo, de 112[grados].

Posteriormente, al comparar las angulaciones obtenidas durante las maniobras con aquellas del paciente en posicion neutra observamos los grados de movilidad en cada uno de los segmentos cervicales evaluados que estan consignados en la Tabla 2.

DISCUSION

El trauma cervical ocurre en el 1,5 % de todos los traumatismos mayores; generalmente es ocasionado por accidentes de transito, en hombres jovenes entre los 15 y los 35 anos, por caidas, u otras lesiones penetrantes y deportivas (8). Teniendo en cuenta que la incidencia de via aerea dificil puede ser mayor en estos pacientes, y que hasta el 28 % de las demandas por muerte y lesion cerebral permanente relacionada con anestesia corresponde a eventos respiratorios, segun el analisis de Closed Claims, de la Sociedad Americana de Anestesiologia (9), es primordial para los anestesiologos realizar un manejo optimo de la via aerea en estos pacientes.

En la actualidad se recomienda que en el escenario de trauma cervical se realice la intubacion orotraqueal con inmovilizacion o proteccion cervical manual (10). Sin embargo, esta maniobra de inmovilizacion impide muy a menudo la visualizacion laringea, y genera dificultades en la intubacion (11-13). Por ello, se ha descrito el uso de multiples dispositivos para facilitar la visualizacion glotica y la intubacion orotraqueal.

Estudios realizados para evaluar el impacto del uso de hojas Macintosh mostraron que la mayor extension se produce entre el occipucio y C1, y entre C1 y C2, y que es menor en los segmentos subaxiales (1,14,15). Existen comparaciones entre la laringoscopia directa con hojas Miller y hojas Macintosh, en las cuales se ha encontrado que, no obstante una menor extension cervical con las hojas Miller (9,5 + -3,8 vs. 12,1 + -4,9, p = 0,012), esta es despreciable, y, probablemente, no es importante en la practica clinica (16).

El estilete luminoso es una herramienta util para facilitar la intubacion orotraqueal en pacientes con via aerea dificil (trauma cervical, micrognatia, macroglosia, inmovilidad mandibular) (17-20). Puede ser utilizado como dispositivo unico, y tambien, combinado con otros, para facilitar el acceso a la via aerea. Ademas, a diferencia de los instrumentos fibroopticos, los estiletes luminosos pueden limpiarse y esterilizarse con rapidez, y son facilmente transportables, requieren una minima preparacion previa durante situaciones de emergencia y estan altamente disponibles (21).

No se ha observado diferencia en la movilidad de la columna cervical durante la intubacion orotraqueal con estilete luminoso vs. fibrobroncoscopio flexible (12[grados] + -6[grados] vs. 11[grados] + -5[grados]; p = 0,5). Los segmentos de mayor desplazamiento son C0-1 y C1-2, que presentan mayor movimiento durante la introduccion de ambos dispositivos (22). El tiempo requerido para la intubacion es menor con respecto al fibrobroncoscopio flexible (34 + -17s vs. 60 + -15s; p < 0,001) (22).

Se ha demostrado que se requiere un menor tiempo para la intubacion orotraqueal con estilete luminoso vs. Fastrach (23,9 + -9 s vs. 71 + -24 s); tambien, que tiene una mayor tasa de intubacion en el primer intento (90,5 % vs. 79,8 %) (23).

El desplazamiento de la columna cervical en cuatro segmentos evaluados (Occipucio- C1, C1-2, C2-5, C5-segmento toracico), es un 57 % menor utilizando el estilete luminoso, en comparacion con la laringoscopia con hoja Macintosh (p = 0,03), sin diferencia significativa en el tiempo requerido para la intubacion con las dos tecnicas; aunque la intubacion con Glidescope es comparable con la del estilete luminoso con respecto al desplazamiento cervical, con el Glidescope el tiempo requerido es un 62 % mayor que con el estilete luminoso (24).

En nuestro estudio los puntos criticos de movimiento en la columna cervical fueron C1 y C5, lo cual es comparable con resultados de estudios previos. Al comparar las dos tecnicas de intubacion utilizadas en el estudio (la laringoscopia con proteccion cervical y la intubacion con estilete luminoso) vemos como la angulacion cervical en estos puntos criticos, C1 y C5, es menor con la utilizacion del estilete luminoso (8[grados]vs. 13,2[grados] en C1, y 6,4[grados] vs. 15,6[grados] en C5) con respecto a las mediciones realizadas con la cabeza en posicion neutra. La realizacion de la triple maniobra y la fijacion del tubo endotraqueal producen angulaciones menores, comparadas con las producidas durante las maniobra de intubacion.

Reconocemos la limitacion del estudio en cuanto al tamano de muestra utilizada, que de otra forma nos permitiria una mayor validez de los resultados. Sin embargo, si analizamos los resultados obtenidos vemos no solo que la intubacion con estilete luminoso produce menor angulacion cervical que la intubacion con laringoscopio con proteccion cervical, sino que se puede comparar con el laringoscopio de Bullard, con el cual se reportan angulaciones hasta de 4[grados] en C5, y con el fibrobroncoscopio, que reporta angulaciones hasta de 7[grados] en C1.

Es importante mencionar que en el presente estudio unicamente se utilizaron hojas rectas (Miller) para evaluar la movilidad cervical, pues en nuestra institucion existe un gran porcentaje de utilizacion rutinaria de hojas Miller para la laringoscopia directa. Sin embargo, el uso de hojas curvas (Macintosh) es una practica comun entre los anestesiologos, y una de las principales motivaciones para elegir una u otra consiste en la preferencia y experiencia del anestesiologo en cuestion, ademas de la disponibilidad de ambas. Aunque no hay estudios que demuestren la preferencia de los anestesiologos en Colombia por alguno de los dos dispositivos, consideramos que podria existir una limitacion para la aplicabilidad de los resultados de nuestro estudio.

La intubacion con estilete luminoso es una herramienta util en pacientes con trauma cervical sin estomago lleno. Debe ser considerada como una alternativa para el manejo de la via aerea en estos pacientes.

doi: 10.5554/rca.v39i1.71

Recibido: julio 29 de 2010. Enviado para modificaciones: agosto 28 de 2010. Aceptado: octubre 9 de 2010.

AGRADECIMIENTOS

Al Dr. Orlando Diaz y la Dra. Sonia Bermudez, del Departamento de Imagenes Diagnosticas de la Fundacion Santa Fe, de Bogota; y a la Dra. Alexandra Chaves, por su colaboracion en la realizacion del presente estudio.
Tabla 1. Promedio de las angulaciones
cervicales con las diversas tecnicas

Tecnicas de       C1     C2     C3     C4      C5
manipulacion de
la via aerea

Posicion          79     90    91,6    90     95,2
  neutral
Triple            72    90,8   92,4   93,6    99,4
  maniobra
Laringoscopia    65,8   90,6   94,4   100,8   110,8
  con
  proteccion
  cervical
Estilete          71    91,6   93,6    99     101,6
  luminoso
Fijacion de      70,4   90,8   90,8   93,6    98,4
  tubo oro
  traqueal

Tabla 2. Promedio de las angulaciones cervicales
en comparacion con la posicion neutra

Tecnicas de        C1         C2         C3         C4         C5
manipulacion
de la via
aerea

Triple             7         0,8        0,8        3,6        4,2
  maniobra      [grados]   [grados]   [grados]   [grados]   [grados]
Laringoscopia     13,2       0,6        2,8        10,8       15,6
  con           [grados]   [grados]   [grados]   [grados]   [grados]
  proteccion
  cervical
Estilete           8         1,6         2          9         6,4
  luminoso      [grados]   [grados]   [grados]   [grados]   [grados]
Fijacion de       8,6        0,8        0,8        3,6        3,8
  tubo oro      [grados]   [grados]   [grados]   [grados]   [grados]
  traqueal


Radiological Measurement of Cervical Angulation Comparing Direct Laryngoscopy with miller Blade vs. lightwand

INTRODUCTION

Tongue and epiglottis displacement occurs during direct laryngoscopy and orotracheal intubation, in addition to cranial-cervical extension to align the oral, pharyngeal and laryngeal axis and to enable the visualization of the glottis (1). Maintaining a safe and patent airway to ensure oxygenation and to prevent the aspiration of gastric contents is one of the key treatment objectives in patients with trauma injuries or other pathologies related to instability of the cervical spine (2).

Although direct laryngoscopy is a reliable and readily available technique, its use in cervical spine instability patients, even under cervical protection, may result in extension of the cervical spine and increase the risk of spinal cord injuries (3-7).

No cinefluoroscopy studies have been made to assess cervical displacement comparing the lightwand versus direct laryngoscopy with the Miller blade. Hence, the main objective of this study was to compare the cervical spine motion during direct laryngoscopy with Miller blade and cervical protection, versus the triple maneuver and intubation with the lightwand in patients with no difficult airway predictors, undergoing interventionist radiology procedures under general anesthesia.

METHODS

This was an observational study of a series of cases including five patients over 18 years of age, who signed the informed consent and were scheduled for embolization of cerebral arteriovenous malformation, with no difficult airway predictors. The exclusion criteria were patients who underwent emergency procedures with a history of coronary disease, high blood pressure, lung disease or coagulation disorders, full stomach and preexisting oral or pharyngeal pathology.

The patients included had met the inclusion and exclusion criteria for three months and agreed to be part of the trial. Venous access was previously secured and vital signs monitoring was in place: EKG, BP, pulse oximetry. The induction was achieved with midazolam 0.01 - 0.03 mg/ Kg, fentanyl 0.5 - 3.5 mg/Kg, sodium thiopental 2 - 6 mg/Kg and rocuronium 0.6 - 1 mg/Kg was administered as a musle relaxant.

When the patient reached the appropriate anesthetic level, an initial fluoroscopic lateral image of the cervical spine was obtained, with the head in neutral position (Figure 1a), using a facemask to maintain the patient ventilated; a second image was captured performing the triple maneuver (Figure 1b); and a third image using direct laryngoscopy with the Miller blade, until the vocal cords were visualized (Figure 1c). A fourth image visualized the light rhombus resulting from the transillumination of the lightwand (Figure 1d); and a final image of the patient intubated and with the head in the position obtained after fixing the tube (Figure 1e). The neuroradiologist obtained these images at the hemodynamics room, with an ANGIOMAT 6000 unit, a General Electric digital injection system that renders images using digital substraction techniques.

Mobility segments of the cervical vertebrae were defined for the measurements obtained, taking as a limit a line drawn between the lower cortical margin of the vertebra and the lower margin of the spinous process of the corresponding vertebra. The angles were measured using a line parallel to the longitudinal axis of the hemodynamics table.

[FIGURE 1 OMITTED]

A neuroradiologist made the readings of the various images and their respective measurements and angulations along each one of the cervical segments; central trend measurements were then obtained using descriptive statistics.

RESULTS

The sample studied belongs to 5 women, average age of 43 years. The angulations of the cervical segments were measured during the different positions as shown in Table 1.

In C1 the minimum value measured with laryngoscopy was 60[degrees] and the maximum 72[degrees]. The minimum value with the lightwand was 66[degrees] and the maximum 82[degrees]. In C5 the minimum value measured with laryngoscopy was 100[degrees], and the maximum 120[degrees]. With the lightwand, the minimum value obtained was 98[degrees], and the maximum 112[degrees].

Later on, when comparing the angulations obtained using the maneuvers with the patient in neutral position, the degrees of motion in each cervical segment assessed were observed, as shown in Table 2.

DISCUSSION

Cervical trauma occurs in 1.5 % or every major trauma; it is usually caused by traffic accidents in young men 15 to 35 years old and by falls or other penetrating and sports injuries (8). Taking into account that the incidence of difficult airway may be higher in these patients, and that up to 28 % of the legal claims for anesthesia-related deaths and permanent brain injury are due to respiratory events -according to the analysis of Closed Claims of the American Society of Anesthesia (9)--it is mandatory for anesthesiologist to do an optimal management of the airway in these patients.

The current recommendations for cervical trauma indicate orotracheal intubation with immobilization or manual cervical protection (10). However, very often the immobilization maneuver hinders the visualization of the larynx and creates difficulties for intubation (11-13). Hence, the use of multiple devices has been described to facilitate the visualization of the glottis and orotracheal intubation.

Studies aimed at assessing the impact of using Macintosh blades showed that the longer extension occurs between the occiput and C1, and between C1 and C2; the extension is shorter in the sub-axial segments (1,14,15). Comparisons between direct laryngoscopy with Miller blades versus Macintosh blades have shown that despite a shorter cervical extension with the Miller blades (9.5+-3.8 vs. 12.1 +-4.9, p = 0.012), such shorter cervical extension is neglectable and probably unimportant for clinical practice (16).

The lightwand is a useful tool to facilitate orotracheal intubation in difficult airway patients (cervical trauma, micrognatia, macroglosia, mandibular immobility) (17-20). The lightwand can be used alone or in combination with other devices to facilitate airway access. Furthermore, in contrast with fiberoptic instruments, lightwands are easily cleaned and sterilized and are easy to transport, require minimal prep in emergency situations and are readily available (21).

No differences in mobility of the cervical spine have been found during orotracheal intubation with the lightwand vs. the flexible fiberscope (12[degrees] + -6[degrees] vs. 11[degrees] + -5[degrees]; p = 0.5). The segments with larger displacement are C0-1 and C1-2, exhibiting greater mobility during the introduction of both devices (22). Intubation time is shorter with the flexible fiberscope (34 + -17s vs. 60 + -15 s; p < 0.001) (22).

It has been shown that a shorter time is required for orotracheal intubation using the lightwand vs. Fastrach (23.9 + -9 s vs. 71 + -24 s) as well as a higher first attempt success rate (90,5 % vs. 79,8 %) (23).

The displacement of the cervical spine in the four segments assessed (Occiput- C1, C1-2, C25, C5-toracic segment) is 57 % less using the lightwand versus laryngoscopy with the Macintosh blade (p=0.03), with no significant difference in the time required for intubation using any of the two techniques. Although the intubation with the Glidescope is comparable to the lightwand in terms of cervical displacement, the time required using the Glidescope is 62 % longer that with the lightwand (24).

In our study, the critical points in terms of movement of the cervical spine were C1 and C5, which is comparable to the results of previous studies. When comparing both intubation techniques used in the study (laryngoscopy with cervical protection vs. lightwand intubation), the cervical angulation at the critical points -C1 and C5- is less when using the lightwand (8[degrees] vs. 13.2[degrees] in C1, and 6.4[degrees] vs. 15.6[degrees] in C5), with regards to the measurements taken with the head in neutral position. The triple maneuver and the fixation of the endotracheal tube result in smaller angulations as compared with the angulations obtained during the intubation maneuver.

We acknowledge the limitation of this study in terms of the size of the sample used which otherwise would enhance the validity of the results. However, the analysis of the results indicates that intubation with the lightwand not only reduces the cervical angulation as compared to intubation with the laryngoscope and cervical protection, but is also comparable to the Bullard laryngoscope that reports up to 4[degrees] angulations in C5, and to the fiberbroncoscope that reports up to 7[degrees] angulations in C1.

It is important to mention that only straight blades (Miller) were used in this study to assess cervical mobility, because there is a high percentage of routine utilization of Miller blades for direct laryngoscopy at our institution. However, the use of curved blades (Macintosh) is a common practice among anesthetists and one of the key reasons for choosing one against the other is the preference and experience of the practicing anesthetist, in addition to availability of the devices. Although there are no studies showing the preference of anesthetists in Colombia for any of these two devices, we believe that there could be a limitation for the applicability of the results of the study.

Lightwand intubation is a useful tool in cervical trauma patients with an empty stomach and should be considered an alternative airway management approach in these patients.

ACKNOWLEDGEMENTS

We would like to express our gratitude to Dr. Orlando Diaz and Dr. Sonia Bermudez, of the Department of diagnostic Images of the Santa Fe Foundation, Bogota and to Dr. Alexandra Chaves, for their collaboration with this study.

REFERENCES

(1.) Sawin PD, Todd MM, Traynelis VC, Farrell SB, Nader A, Sato Y, et al. Cervical spine motion with direct laryngoscopy and orotracheal intubation: an in vivo cinefluoroscopic study of subjects without cervical abnormality. Anesthesiology. 1996; 85(1):26-36.

(2.) Langeron O, Birenbaum A, Amour J. Airway management in trauma. Minerva Anestesiol. 2009; 75(5): 307-11.

(3.) Suderman VS, Crosby ET, Lui A. Elective oral tracheal intubation in cervical spine--injured adults. Can J Anaesth. 1991; 38(6):785-9.

(4.) Calder I, Calder J, Crockard HA. Difficult direct laryngoscopy in patients with cervical spine disease. Anaesthesia. 1995; 50(9):756-63.

(5.) Hastings RH, Wood PR. Head extension and laryngeal view during laryngoscopy with cervical spine stabilization maneuvers. Anesthesiology. 1994; 80(4): 825-31.

(6.) Lennarson PJ, Smith D, Todd MM, Carras D, Sawin PD, Brayton J, et al. Segmental cervical spine motion during orotracheal intubation of the intact and injured spine with and without external stabilization. J Neurosurg. 2000; 92(2Suppl):201-6.

(7.) McLeod ADM, Calder I. Spinal cord injury and direct laryngoscopy--the legend lives on. Br J Anaesth. 2000; 84(6):705-9.

(8.) Bryson BL, Mulkey M, Mumford B. Cervical spine injury, incidence and diagnosis. J Trauma. 1986; 26(7):669-74.

(9.) Cheney FW, Posner KL, Lee LA, Caplan RA, Domino KB. Trends in anesthesia-related death and brain damage: a closed claims analysis. Anesthesiology. 2006; 105(6):1081-6.

(10.) American College of Surgeons Committee on Trauma. Advanced trauma life support course for doctors. 6th ed. Chicago: American College of Surgeons; 1997.

(11.) Nolan JP, Wilson ME. Orotracheal intubation in patients with potential cervical spine injuries. An indication for the gum elastic bougie. Anaesthesia. 1993; 48(7):630-3.

(12.) Hastings RH, Wood PR. Head extension and laryngeal view during laryngoscopy with cervical spine stabilization maneuvers. Anesthesiology. 1994; 80(4): 825-31.

(13.) Heath KJ. The effect of laryngoscopy of different cervical spine immobilisation techniques. Anaesthesia. 1994; 49(10):843-5.

(14.) Hastings RH, Vigil AC, Hanna R, Yang BY, Sartoris DJ. Cervical spine movement during laryngoscopy with the Bullard, Macintosh, and Miller laryngoscopes. Anesthesiology. 1995; 82(4):859-69.

(15.) Watts AD, Gelb AW, Bach DB, Pelz DM. Comparison of the Bullard and Macintosh laryngoscopes for endotracheal intubation of patients with a potential cervical spine injury. Anesthesiology. 1997; 87(6): 1335-42.

(16.) LeGrand SA, Hindman BJ, Dexter F, Weeks JB, Todd MM. Craniocervical motion during direct laryngoscopy and orotracheal intubation with the Macintosh and Miller blades: an in vivo cinefluoroscopic study. Anesthesiology. 2007; 107(6):884-91.

(17.) Hung OR, Stewart RD. Lightwand intubation: I--a new lightwand device. Can J Anaesth. 1995; 42(9):820-5.

(18.) Hung OR, Pytka S, Morris I, Murphy M, Steward RD. Lightwand intubation: II--clinical trial of a new lightwand for tracheal intubation in patients with difficult airways. Can J Anaesth. 1995; 42(9):826-30.

(19.) Paschen HR. Difficult airway management in trauma-transillumination devices. Trauma Care 99, Proceedings of the 12th Annual Trauma Anesthesia and Critical Care Symposium; 13-15 Mayo 1999, Chicago.

(20.) Davis L, Cook-Sather SD, Schreiner MS. Lighted stylet tracheal intubation: a review. Anesth Analg. 2000; 90(3):745-56.

(21.) Smith CE, DeJoy SJ. New equipment and techniques for airway management in trauma. Curr Opin Anaesthesiol. 2001; 14(2):197-209.

(22.) Houde B, Williams SR, Cadrin-Chenevert A, Drolet P. A comparison of cervical spine motion during orotracheal intubation with the trachlight(r) or the flexible fiberoptic bronchoscope. Anesth Analg. 2009; 108(5):1638-43.

(23.) Inoue Y, Koga K, Shigematsu A. A comparison of two tracheal intubation techniques with trachlight and Fastrach in patients with cervical spine disorders. Anesth Analg. 2002; 94(3):667-71.

(24.) Turkstra TP, Craen R, Pelz DM, Gelb AW. Cervical spine motion: a fluoroscopic comparison during intubation with lighted stylet, GlideScope, and Macintosh laryngoscope. Anesth Analg. 2005; 101(3): 910-5.

Conflicto de intereses: ninguno declarado

Maria Claudia Nino, Medica neuroanestesiologa. Hospital Universitario Fundacion Santa Fe. Bogota, Colombia, e-mail: gigi87@yahoo.com

Francisco Jose Ramirez, Medico anestesiologo e intensivista. Jefe de la Unidad de Cuidado Intensivo de la Clinica Santa Ana, Cucuta, Colombia.

Andrea Carolina Perez Pradilla, Medica residente de tercer ano de Anestesiologia y Reanimacion en la Universidad El Bosque. Hospital Universitario Fundacion Santa Fe. Bogota, Colombia.
Table 1. Average of cervical angulations using
the various techniques

Airway          C1     C2     C3     C4      C5
manipulation
techniques

Neutral         79     90    91.6    90     95.2
  Position
Triple          72    90.8   92.4   93.6    99.4
  maneuver
Laryngoscopy
  with         65.8   90.6   94.4   100.8   110.8
  cervical
  protection
Lightwand       71    91.6   93.6    99     101.6
Fixation       70.4   90.8   90.8   93.6    98.4
  of the
  orotracheal
  tube

Table 2. Average of Cervical Angulations
Compared Against the Neutral Position

Airway              C1         C2          C3
manipulation
techniques

Triple              7          0,8         0.8
  maneuver      [degrees]   [degrees]   [degrees]
Laryngoscopy      13.2         0.6         2.8
  with          [degrees]   [degrees]   [degrees]
  cervical
  protection
Lightwand           8          1.6          2
                [degrees]   [degrees]   [degrees]
Fixation           8.6         0.8         0.8
  of the        [degrees]   [degrees]   [degrees]
  orotracheal
  tube

Airway             C4         C5
manipulation
techniques

Triple             3.6         4.2
  maneuver      [degrees]   [degrees]
Laryngoscopy      10.8       15.6
  with          [degrees]   [degrees]
  cervical
  protection
Lightwand           9          6.4
                [degrees]   [degrees]
Fixation           3.6         3.8
  of the        [degrees]   [degrees]
  orotracheal
  tube
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Article Details
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Title Annotation:Reporte de Caso
Author:Claudia Nino, Maria; Jose Ramirez, Francisco; Perez Pradilla, Andrea Carolina
Publication:Revista Colombiana de Anestesiologia
Article Type:Clinical report
Date:Feb 1, 2011
Words:4478
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