Intubation : Quoi de neuf? DESC Réanimation Thomas Reydel 12 décembre 2012

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1 Intubation : Quoi de neuf? DESC Réanimation Thomas Reydel 12 décembre 2012

2 Introduction - Intubation trachéale : principe simple - Amélioration via technologie (SpO2 Capno) Cheney FW et al. Trends in anesthesia-related death and brain damage : a closed claims analysis. Anesthesiology La difficultés augmentent dans les situations d urgence : 4 % 22 % Martin LD et al. Emergency tracheal intubations at a university hospital : airway outcomes and complications. Anesthesiology 2011

3 Intubation en Réanimation - Difficile dans 10 % des cas. Jaber S et al. An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Intensive Care Med Le patient critique : intubation non différable. - Pas d anticipation des difficultés. - Complications hémodynamiques et respiratoires. - Vacuité gastrique Jaber S et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Crit Care Med 2006

4 Solutions - Facteurs identifiés Jimson et al. Predicting difficult endotracheal intubation in surgical patients scheduled for general anesthesia. Anesth Analg Sociétés savantes Gene et al. Management of the difficult airway, a closed claims analysis. Anesthesiology 2005

5 Solutions - Facteurs identifiés Jimson et al. Predicting difficult endotracheal intubation in surgical patients scheduled for general anesthesia. Anesth Analg Sociétés savantes Gene et al. Management of the difficult airway, a closed claims analysis. Anesthesiology 2005

6 Solutions - Facteurs identifiés Jimson et al. Predicting difficult endotracheal intubation in surgical patients scheduled for general anesthesia. Anesth Analg Sociétés savantes Gene et al. Management of the difficult airway, a closed claims analysis. Anesthesiology 2005

7 Solutions - Facteurs identifiés Jimson et al. Predicting difficult endotracheal intubation in surgical patients scheduled for general anesthesia. Anesth Analg Sociétés savantes Gene et al. Management of the difficult airway, a closed claims analysis. Anesthesiology 2005 Morbi-mortalité liée à l intubation reste élevée

8 Les Laryngoscopes Macintosh Miller

9 Evolution Masque Laryngé Bullard Laryngo Mac Coy Fasttrach LMA CTrach

10 Pourquoi se limiter? 2012

11 Pourquoi se limiter? Jonathan Berall (1997) Camera Screen Laryngoscope

12 GLOTTISCOPE VIDÉOLARYNGOSCOPE Video Airtraq GlideScope Mac Grath Pentax AWS C-Mac with D-Blade Truview EVO2

13 Littérature abondante

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23 Points positifs - Vidéo laryngoscopie : réduction d intubation dans l œsophage (GlideScope) par novices. Hirabayashi Y et al. GlideScope videolaryngoscope reduces the incidence of erroneous esophageal intubation by novice laryngoscopists. J Anesth Facile : 36 % échec en pré hospitalier à 4 % après formation courte - Arrêt cardiaque : MCE continu Rothfield KP et al. Videolaryngoscopy improves emergency medical services intubation sucess in cardiac arrest patient. Circulation 2011

24 Points positifs - GlideScope : 51 % intubation vs 90 % par des manipulateurs inexpérimentés ; 89sec vs 63sec. Nouruzi-Sedeh P et al.laryngoscopy via macintosh blade versus GlideScope : sucess rate and time for endotracheal intubation in untrained medical personnel. Anesthesiology GlideScope pour intubation difficile prévue : 98 % de succès et rattrape 94 % si laryngo direct inefficace Aziz MF et al. Routine clinical practice effectiveness of the GlideScope in difficult airway managemement : an analysis of 2400 GlideScope intubations, complications, and failures from two institutions. Anesthesiology 2011

25 Points positifs - Améliore vue patients aux ATCD Cormack 3/4 Cooper RM et al; Use of a new videolaryngoscope (GlideScope) in the management of a difficult airway. Can J Anesth Moins traumatique et meilleure vue Russel T et al. A comparaison of the forces applied to a manikin during laryngoscopy with the GlideScope and Macintosh laryngoscopes. Anesth Intensive Care 2011

26 Points positifs - Améliore vue patients aux ATCD Cormack 3/4 Cooper RM et al; Use of a new videolaryngoscope (GlideScope) in the management of a difficult airway. Can J Anesth Moins traumatique et meilleure vue Russel T et al. A comparaison of the forces applied to a manikin during laryngoscopy with the GlideScope and Macintosh laryngoscopes. Anesth Intensive Care 2011

27 Points positifs - Moins traumatique sur les dents Russel et al. Measurement of forces applied during Macintosh direct laryngoscopy compared with GlideScope videolaryngoscopy, Anaesthesia Moins de mouvement du rachis cervical Yoshihiro et al. Distorsion of anterior airway anbatomy during laryngoscopy with the GlideScope videolaryngoscope. J Anesth 2010.

28 Macintosh - Difficile à enseigner et pratique longue Plummer JL et al. Learning endotracheal intubation in a clinical skills learning center : a quantitative study. Anesth Analg Seul le manipulateur voit - 50 % de succès sur les 10 premieres IOT % aide nécessaire après 80 IOT. Konrad C et al. Learning manual skills in anesthesiology. Aneth Analg 1998

29 - 37 novices (expérience < 6 laryngoscopies) - 2 groupes : V/T et T/V - Patients faciles (Cormack 1 ou 2)

30 Laryngoscopie video-assistée serait moins traumatisante (mais non significatif)

31 Comparaisons 1 vs 1 - GlideScope Sun DA et al. The GlideScope Video laryngoscope : randomized clinical trial in 200 patients. Br J Anaesth TruView Li JB et al. An evaluation of TruView EVO2 laryngoscope. Anesthésia Pentax AWS - Airtraq Enomoto Y et al. Pentax AWS, a new videolaryngoscope for tracheal intubation in patients with restrictive neck movements : a randomized comparative study. Br J Anaesth 2008 Maharaj CH et al. Evaluations of intubation using the Airtraq or Macintosh laryngoscope by anaesthesists in easy and simulated difficult laryngoscopy. Anaesthesia 2006

32 Comparaisons 1 vs 1 - GlideScope Sun DA et al. The GlideScope Video laryngoscope : randomized clinical trial in 200 patients. Br J Anaesth 2005 MEILLEURE VUE - TruView Li JB et al. An evaluation of TruView EVO2 laryngoscope. Anesthésia Pentax AWS - Airtraq Enomoto Y et al. Pentax AWS, a new videolaryngoscope for tracheal intubation in patients with restrictive neck movements : a randomized comparative study. Br J Anaesth 2008 Maharaj CH et al. Evaluations of intubation using the Airtraq or Macintosh laryngoscope by anaesthesists in easy and simulated difficult laryngoscopy. Anaesthesia 2006

33 Comparaisons 1 vs 1 - GlideScope Sun DA et al. The GlideScope Video laryngoscope : randomized clinical trial in 200 patients. Br J Anaesth 2005 MEILLEURE VUE - TruView - Pentax AWS - Airtraq Li JB et al. An evaluation of TruView EVO2 laryngoscope. Anesthésia 2007 MEILLEURE VUE, SURTOUT C&L > 1 Enomoto Y et al. Pentax AWS, a new videolaryngoscope for tracheal intubation in patients with restrictive neck movements : a randomized comparative study. Br J Anaesth 2008 Maharaj CH et al. Evaluations of intubation using the Airtraq or Macintosh laryngoscope by anaesthesists in easy and simulated difficult laryngoscopy. Anaesthesia 2006

34 Comparaisons 1 vs 1 - GlideScope Sun DA et al. The GlideScope Video laryngoscope : randomized clinical trial in 200 patients. Br J Anaesth 2005 MEILLEURE VUE - TruView - Pentax AWS - Airtraq Li JB et al. An evaluation of TruView EVO2 laryngoscope. Anesthésia 2007 MEILLEURE VUE, SURTOUT C&L > 1 Enomoto Y et al. Pentax AWS, a new videolaryngoscope for tracheal intubation in patients with restrictive neck movements : a randomized comparative study. Br J Anaesth 2008 MEILLEURE VUE, SUCCES Maharaj CH et al. Evaluations of intubation using the Airtraq or Macintosh laryngoscope by anaesthesists in easy and simulated difficult laryngoscopy. Anaesthesia 2006

35 Comparaisons 1 vs 1 - GlideScope Sun DA et al. The GlideScope Video laryngoscope : randomized clinical trial in 200 patients. Br J Anaesth 2005 MEILLEURE VUE - TruView - Pentax AWS - Airtraq Li JB et al. An evaluation of TruView EVO2 laryngoscope. Anesthésia 2007 MEILLEURE VUE, SURTOUT C&L > 1 Enomoto Y et al. Pentax AWS, a new videolaryngoscope for tracheal intubation in patients with restrictive neck movements : a randomized comparative study. Br J Anaesth 2008 MEILLEURE VUE, SUCCES Maharaj CH et al. Evaluations of intubation using the Airtraq or Macintosh laryngoscope by anaesthesists in easy and simulated difficult laryngoscopy. Anaesthesia 2006 FACILE UTILISATION, SUCCÈS, MOINS TRAUMATIQUE, PLUS RAPIDE

36 Comparaisons 1 vs 1 - GlideScope Sun DA et al. The GlideScope Video laryngoscope : randomized clinical trial in 200 patients. Br J Anaesth TruView Li JB et al. An evaluation of TruView EVO2 laryngoscope. Anesthésia Pentax AWS - Airtraq Enomoto Y et al. Pentax AWS, a new videolaryngoscope for tracheal intubation in patients with restrictive neck movements : a randomized comparative study. Br J Anaesth 2008 Maharaj CH et al. Evaluations of ease of intubation with the Airtraq or Macintosh laryngoscope by anaesthesists in easy and simulated difficult laryngoscopy. Anaesthesia 2006

37 Comparaisons 1 vs 1 - GlideScope Sun DA et al. The GlideScope Video laryngoscope : randomized clinical trial in 200 patients. Br J Anaesth 2005 INTUBATION PLUS LONGUE C&L FACILE - TruView Li JB et al. An evaluation of TruView EVO2 laryngoscope. Anesthésia Pentax AWS - Airtraq Enomoto Y et al. Pentax AWS, a new videolaryngoscope for tracheal intubation in patients with restrictive neck movements : a randomized comparative study. Br J Anaesth 2008 Maharaj CH et al. Evaluations of ease of intubation with the Airtraq or Macintosh laryngoscope by anaesthesists in easy and simulated difficult laryngoscopy. Anaesthesia 2006

38 Comparaisons 1 vs 1 - GlideScope Sun DA et al. The GlideScope Video laryngoscope : randomized clinical trial in 200 patients. Br J Anaesth 2005 INTUBATION PLUS LONGUE C&L FACILE - TruView - Pentax AWS Li JB et al. An evaluation of TruView EVO2 laryngoscope. Anesthésia 2007 TEMPS D INTUBATION PLUS LONG Enomoto Y et al. Pentax AWS, a new videolaryngoscope for tracheal intubation in patients with restrictive neck movements : a randomized comparative study. Br J Anaesth Airtraq Maharaj CH et al. Evaluations of ease of intubation with the Airtraq or Macintosh laryngoscope by anaesthesists in easy and simulated difficult laryngoscopy. Anaesthesia 2006

39 Comparaisons 1 vs 1 - GlideScope Sun DA et al. The GlideScope Video laryngoscope : randomized clinical trial in 200 patients. Br J Anaesth 2005 INTUBATION PLUS LONGUE C&L FACILE - TruView - Pentax AWS - Airtraq Li JB et al. An evaluation of TruView EVO2 laryngoscope. Anesthésia 2007 TEMPS D INTUBATION PLUS LONG Enomoto Y et al. Pentax AWS, a new videolaryngoscope for tracheal intubation in patients with restrictive neck movements : a randomized comparative study. Br J Anaesth 2008 TEMPS D INTUBATION IDENTIQUE Maharaj CH et al. Evaluations of ease of intubation with the Airtraq or Macintosh laryngoscope by anaesthesists in easy and simulated difficult laryngoscopy. Anaesthesia 2006

40 Comparaisons 1 vs 1 - GlideScope Sun DA et al. The GlideScope Video laryngoscope : randomized clinical trial in 200 patients. Br J Anaesth 2005 INTUBATION PLUS LONGUE C&L FACILE - TruView - Pentax AWS - Airtraq Li JB et al. An evaluation of TruView EVO2 laryngoscope. Anesthésia 2007 TEMPS D INTUBATION PLUS LONG Enomoto Y et al. Pentax AWS, a new videolaryngoscope for tracheal intubation in patients with restrictive neck movements : a randomized comparative study. Br J Anaesth 2008 TEMPS D INTUBATION IDENTIQUE Maharaj CH et al. Evaluations of ease of intubation with the Airtraq or Macintosh laryngoscope by anaesthesists in easy and simulated difficult laryngoscopy. Anaesthesia 2006 CARACTERISQUES IDENTIQUES SI INTUBATION FACILE

41 Points négatifs - 22 % de laryngo direct Cormack 3-4 reste pareil avec VideoLaryngoscopie Brown CA et al. Improved glottic exposure with the video Macintosh laryngoscope in adult emergency department tracheal intubations. Ann Emerg Med ,5 % echec avec C-Mac en préhospitalier Cavus E et al. The C-Mac videolaryngoscope for prehospital emergency intubation : a prospective, multicentre, obsevational study. Emergency Med J 2011

42 Points négatifs - Technologie Rothfield KP et al. Comparison of GlideScope to conventional laryngoscopy for emergency intubation by non anesthesia providers. Anesth Analg Video bien pour les débutants (1) mais pas pour les initiés (2) Walker L et al. Randomized controlled trial of intubation with the McGrath series 5 viudeolaryngoscope by inexperienced anesthesists. Br J Anesth 2012 Griesdale DE et al. GlideScope videolaryngoscopy versus direct laryngoscopy for endotracheal intubation : a systemic review and meta-analysis. Can J Anesth Inventeur GlideScope et Pentax AWS sont tous les deux des chirurgiens

43 Comparaison - Mieux que Macintosh? - Lequel?

44 -150 patients avec BMI > 35 kg/m2 randomisés -Laryngoscopie Macintosh primaire (C&L)

45 Nombre de tentatives nécessaire à IOT(lié au Cormack) : -2,6 +/-1,0 GlideScope -1,4 +/- 0,7 V-MAC -2,9 +/-0,9 Mc Grath Utilisation d un mandrin -60 % GlideScope -10 % V-MAC -76 % Mc Grath Temps d intubation : /- 18 sec GlideScope /- 9 sec V-MAC /- 25 sec Mc Grath Satisfaction meilleur avec V-MAC

46 Nombre de tentatives nécessaire à IOT(lié au Cormack) : -2,6 +/-1,0 GlideScope -1,4 +/- 0,7 V-MAC -2,9 +/-0,9 Mc Grath SATISFACTION, VITESSE, Utilisation d un mandrin -60% GlideScope -10% V-MAC -76% Mc Grath MOINS DE MANDRIN Temps d intubation : /- 18 sec GlideScope /- 9 sec V-MAC /- 25 sec Mc Grath Satisfaction meilleur avec V-MAC

47 - 35 anesthésistes expérimentés - Formation courte initiale - 4 scénarios : simple, rigidité cervicale, œdème de langue, rigidité cervicale + œdème de langue

48 Normal -100 % intubation -Pression dentaire : Pentax <.. < Macintosh Vitesse Intubation Rigidité cervicale -100 % intubation - Pression dentaire : Pentax < 3 autres œdème de langue -Intubation 100% P, 88% GS, 54% T, 9% Mc -Pression dentaire : Pentax < 3 autres Rigidité ET œdème : -Intubation 91% P, 65% GS, 54% T, 11% Mc -Pression dentaire : Pentax < 3 autres

49 SATISFACTION, VITESSE, Normal -100% intubation -Pression dentaire : Pentax <.. < Macintosh EFFICITE EN SITUATION Rigidité cervicale -100% intubation - Pression dentaire : Pentax < 3 autres DIFFICILE, MOINS Oedeme de langue -Intubation 100% P, 88% GS, 54% T, 9% Mc -Pression dentaire : Pentax < 3 autres Rigidité ET œdème : -Intubation 91% P, 65% GS, 54% T, 11% Mc -Pression dentaire : Pentax < 3 autres TRAUMATIQUE

50 - 42 seniors - Apprentissage d utilisation des glottiscopes (théorie et pratique) - 2 situations : intubation standard et intubation difficile (mannequin)

51

52 - GlideScope vs Macintosh - 17 études patients - Intubation simple ou difficile - Novice ou expert - Exposition / Succès / Vitesse

53 EXPOSITION AMELIOREE (SURTOUT SI C&L INITIAL >1)

54 SUCCES POUR LES NOVICES SEULEMENT

55 PLUS RAPIDE POUR LES NOVICES SEULEMENT

56 Vidéo laryngoscope Avantages - Rapproche notre œil de la cible : meilleure vue - Enseignement : facile d utilisation pour les novices avec courbe apprentissage courte - Moins traumatique Inconvénients - Temps d intubation souvent plus long - Les limites de la technologies - Prix - Place dans l algorythme? Mieux voir n est pas synonyme de mieux intuber.

57 Intubation : quoi de neuf? RIEN Pour l instant

58

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