Rev. Bras. Anestesiol. vol.65 número5

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REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

Official Publication of the Brazilian Society of Anesthesiology

www.sba.com.br

SCIENTIFIC

ARTICLE

The

influence

of

airway

supporting

maneuvers

on

glottis

view

in

pediatric

fiberoptic

bronchoscopy

Tarik

Umutoglu

a,∗

,

Ahmet

Hakan

Gedik

b

,

Mefkur

Bakan

a

,

Ufuk

Topuz

a

,

Hayrettin

Daskaya

a

_,

_Erdogan

_Ozturk

a

_,

_Erkan

_Cakir

b

_,

_Ziya

_Salihoglu

a

a_Department_of_{Anesthesiology}_and_Reanimation,_Faculty_of_Medicine,_Bezmialem_Vakif_University,_Istanbul,_Turkey

b_Department_of_Pediatric_Pulmonary_Medicine,_Faculty_of_Medicine,_Bezmialem_Vakif_University,_Istanbul,_Turkey

Received5August2014;accepted17September2014 Availableonline30March2015

KEYWORDS

Fiberoptic bronchoscopy; Pediatrics;

Airwaymaneuvers; Jawtrust;

Glottisview

Abstract

Introduction:Flexiblefiber opticbronchoscopy isavaluableinterventionforevaluationand managementofrespiratorydiseasesinbothinfants,pediatricandadultpatients.Theaimof thisstudyistoinvestigate theinfluenceoftheairwaysupportingmaneuversonglottisview duringpediatricflexiblefiberopticbronchoscopy.

Materialsandmethods: Inthisrandomized,controlled,crossoverstudy;patientsagedbetween 0and 15years whounderwent flexible fiberopticbronchoscopy procedure havingAmerican SocietyofAnesthesiologistsI---IIriskscorewereincluded.Patientshavingriskofdifficult intu-bation,intubatedorpatientswithtracheostomy,andpatientswithreducedneckmobilityor havingcautionsforneckmobilitywereexcludedfromthisstudy.Afterobtainingbestglottic viewattheneutralposition,patientswerepositionedjawtrustwithopenmouth,jawtrust withteethprottution,headtiltchinliftandtripleairwaymaneuversandbestglottisscores wererecorded.

Results:Totalof121pediatricpatients,57girlsand64boys,wereincludedinthisstudy.Both jawtrustwithopenmouthandjawtrustwithteethprottutionmaneuversimprovedtheglottis viewcomparedwithneutralposition(p<0.05),butwedidnotobserveanydifferencebetween jaw trustwith openmouth andjawtrust withteeth prottution maneuvers(p>0.05).Head tilt chinlift and triple airwaymaneuvers improved glottisview when compared withboth jawtrustwithopenmouth andjawtrustwithteethprottutionmaneuversandneutral posi-tion(p<0.05);howeverwefoundnodifferencesbetweenheadtiltchinliftandtripleairway maneuvers(p>0.05).

∗_{Corresponding}_author.

E-mail:umutson77@hotmail.com(T.Umutoglu).

http://dx.doi.org/10.1016/j.bjane.2014.09.016

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Conclusion:Allairwaysupportingmaneuvers improvedglottic viewduringpediatric flexible fiberopticbronchoscopy;howeverheadtiltchinliftandtripleairwaymaneuverswerefoundto bethemosteffectivemaneuvers.

PALAVRAS-CHAVE

Fibrobroncoscopia; Pediatria;

Manobrasdasvias aéreas;

Elevac¸ãoda mandíbula;

Visibilidadedaglote

Ainfluênciadasmanobrasdesuportedasviasaéreassobreavisibilidadedagloteem fibrobroncoscopiapediátrica

Resumo

Introdução:A broncofibroscopia flexível (BF) é uma valiosa intervenção para o manejo e avaliação de doenças respiratórias em pacientestanto pediátricos quanto adultos. O obje-tivodeste estudofoiinvestigar ainfluênciadasmanobrasde apoiodasviasaéreas sobrea visibilidadedagloteduranteaBFpediátrica.

Materialemétodo:Estudocruzado,randômicoecontrolado,incluindopacientescomidades entre0-15anos,ASAI-II,queforamsubmetidosàBF.Pacientescomriscodeintubação difí-cil,entubadosoucomtraqueostomiaeaquelescommobilidadereduzidadopescoçoouque exigissemcuidadosparaamobilidadedopescoçoforamexcluídosdoestudo.Depoisdeobtera melhorvisibilidadedaglotenaposiçãoneutra,ospacientesforamposicionadoscomelevação damandíbulaeaberturadaaberta(EMBA),comelevaçãodamandíbulaeprotrusãodosdentes (EMPD),cominclinaçãodacabeçaelevaçãodoqueixo(ICEQ)ecomatriplamanobradasvias aéreas(TMVA).Osmelhoresescoresdagloteforamregistrados.

Resultados: Nototal,121pacientespediátricosforamincluídosnoestudo:57pacientesdosexo femininoe64dosexomasculino.AmbosasmanobrasEMBAeEMPDmelhoraramavisibilidade dagloteemcomparaçãocomaposiçãoneutra(p<0,05),masnãoobservamosdiferençaentre asmanobrasEMBAeEMPD(p>0,05).AsmanobrasICEQeTMVAmelhoraramavisibilidadeda gloteemcomparaçãocomasmanobrasEMBAeEMPDeaposiçãoneutra(p<0,05);porém,não encontramosdiferençasentreaICEQeaTMVA(p>0,05).

Conclusão:Todasas manobrasde acesso àsvias aéreas melhoraramavisibilidade daglote duranteaBFpediátrica;porém,ainclinaçãodacabeçaeelevaçãodoqueixoeatriplamanobra dasviasaéreasforamconsideradasasmanobrasmaiseficazes.

Introduction

Flexiblefiberopticbronchoscopy(FOB)isavaluable inter-vention for evaluation and management of respiratory diseases in both infants, pediatric and adult patients. Since its first introduction by Ikeda in 1968, fiber optic bronchoscope in clinical practice; it has been 46 years and there have also been a number of other changes in pediatric pulmonology that have consequences on bron-choscopy practice.1 _Most _common _indications _of _FOB _in

pediatric population arepersistent radiological

abnormal-ities, unexplained respiratory distress, and stridor. Also

direct inspectionin patients with suspected foreignbody

aspirations and broncho-alveolar lavage requirement for

patientshavinglunginfectionaretheotherindications.

Children often require deep sedation or general

anes-thesia during FOB procedure.2 _Usually _there _is _a _clear

airwaypresentinawakepatientshoweverinanaesthetized

patients,duetochangesinupperairwaystructures;partial

orcompleteobstructionmakesthefiberopticadvancement

difficult. Reduction in muscle tone during deep sedation

or anesthesiahas effects on upper airway structures like

soft palate, tongue base and epiglottismay be relocated

totheposteriorpharyngealwall.Inordertomaintainclear

airwayinanesthetizedpatients,airway-supporting

maneu-versmayberequiredduringfiberopticbronchoscopy.Also

employment of intubating airways like Berman or

Ovass-apian,directlaryngoscopy,lingualtractionandsupraglottic

airwaydevices(LaryngealMaskAirway,I-GelorIntubating

LaryngealMask,etc.)arethealternativewaysofresolving

thisproblem.3,4

The effects of airway supporting maneuvers on glottis

viewduringFOBarenotstudiedandthereisalackof knowl-edgeinpediatricgroupofpatients.Theaimofthisstudyis

todeterminetheeffectsofairwaysupportingmaneuverson

glottisviewduringflexibleFOBinpediatricpatients.

Materials

and

methods

ThestudyprotocolwasapprovedbytheInstitutionalEthical

CommitteeofBezmialemVakifUniversity.Pediatricpatients

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Table 1 Anterior laryngopharyngeal (LP) view 4 point Chengetal.5_scale.

Grade Description

1 Fullviewofepiglottis,rimaglottidis,corniculate cartilagesandanteriorcommissure.

2 Tipofepiglottisandpartialviewofrimaglottidis andcorniculatecartilagesarevisiblebutanterior commissureofthecordsisnotvisible.

3 Onlytipofepiglottisandcorniculatecartilages arevisiblebutnoneofrimaglottisseen. 4 Onlyfloppyepiglottisseenonposteriorpharynx

butnovisualizationofrimaglottidisand corniculatecartilages.

ofAnesthesiologists(ASA) scoreIor IIscheduled for

flexi-bleFOBbetweenNovember2013andApril2014includedin

thisstudy.Intubatedpatients,patientswithtracheostomy,

patientsrequiringmechanicalventilationsupport,patients

with difficult intubation suspect (Mallampati score 3---4,

micrognathia, craniofacial abnormalities and other

situa-tions related with difficult intubation) and patients with

restrictedneckmobilityorpatientswithcautionsfor neck

mobility were excluded. Patient who had any

contraindi-cations tothe drugs usedin this study wereexcluded. In

accordance withthe Declaration of Helsinki, the purpose

andmethodofthestudyweresufficientlyexplainedtothe

parentsorlegalrepresentativesofeachpatient.Thestudy

wasconductedafterobtaininginformedwrittenconsent.

After usual preoperative fasting interval due to ASA

Guidelines(2hforclearfluids,4hformothermilk,6hfor

diarymilk,formulasandotherfoods).Anintravenous

can-nula inserted at the dorsum of the hand andall patients

premedicated with midazolam 0.03mg/kg and atropine

0.01mg/kg(0.1mgminimum).Topicalanesthesiawith

lido-caine 10% wasapplied tothe nasal mucosaof the nostril

to facilitate FOB for at least 5min before the

interven-tionalprocess.Anesthesiainductionwasmadewithpropofol

1mg/kgandketaminehydrochloride1mg/kgandhypnotic

drugs were utilized to provide deep sedation or general

anesthesia as an adjunct to topical anesthesia for

flexi-blefiberopticbronchoscopy.Patientswerereceivedoxygen

support5L/minwithfacemask afterinitialhypnoticdrug

doseadministration.

Afterinitialadministration,patientswerereceived

con-tinuousketamineandpropofolinfusionswith6---10mg/kg/h

infusionrates.TheRamsaySedationscalewasemployedto

score thesedation level for all patients. The goal wasto

achieveasedationlevelof5or6beforetheprocess.Under

adequatesedationlevelwithsufficientspontaneous

venti-lationwithSpO2>95%FOBprocedurestarted.Patientswere

supine andhead was neutralpositionedduring transnasal

advancement of FOB. Following transnasal advancement

with FOB, anterior and posterior laryngopharyngeal view

evaluated according to 4 and 3 grade scales respectively

adopted from Chenget al.5 _study ₍_Tables ₁ _and ₂_). _After

achievingof the bestview ofanterior or posterior glottis

withneutralposition,additionalairway-supporting

maneu-vers(mentionedbelow)appliedrandomlyandthebestview

Table2 PosteriorLaryngopharyngealview3pointCheng etal.5_scale.

Grade Description

1 Corniculatecartilagesandarytenoidslocated upwardfromposteriorpharynxandbothbase cornersofrimaglottidisarenotvisible. 2 Corniculatecartilagesandarytenoidslocated

upwardfromposteriorpharynxandonlyonebase sidecornerofrimaglottidismayvisible.

3 Corniculatecartilageslocatedonposterior pharynxandarytenoidcartilagesarenotvisible.

ofglottiswitheachmaneuversdocumentedwithvideo

cap-tureimages.

The same bronchoscopist whohad more than 10years

ofexperienceinpediatric flexibleFOBperformed all

pro-cedures and an experienced anesthesiologist apart from

anesthesiamanagement whois blindedfrompatient

posi-tioningandairwaysupportingmaneuversdidtheevaluation

of glottis view from video capture images after the FOB

procedures.

Themaneuversare

1. Jawtrustwithteethprotrusionmaneuver(JTTP),

2. Jawtrustwithopenedmouthmaneuver(JTOM),

3. Headtiltchinliftmaneuver(HTCL),

4. Tripleairwaymaneuver(TA).

Aftercapturing imagesof anteriorandposterior

laryn-gopharyngeal view with 4 different airway supporting

maneuvers, the study finalized and FOB procedure was

accomplished.

Statisticalanalysis

Kruskal---Wallistestwasusedtodetectdifferencesingrades

ofLPtissueseenwiththedifferentairwaysupporting

tech-niques.Ap-valuelessthan0.05wasdefinedasstatistically significant.

Results

DemographicdataforallpatientsareshownintheTable3.

Allbronchoscopieswereaccomplishedsuccessfullyvianasal

approach.Ingeneral,whencomparedwithneutralposition

bothfourairwaysupportingmaneuvers(JTTP,JTOM,HTCL,

TA)clinically and statistically(p<0.05) improved anterior andposteriorlaryngopharyngealviewviaflexiblefiberoptic

bronchoscopy. HTCL and TA maneuvers showed the most

improved glottis view, however there were no significant

differencefoundbetweenJTTP---JTOMmaneuvers(p>0.05)

andHTCL---TAmaneuvers.JTTP,JTOM,HTCL,TAmaneuvers

Table3 Patientdemographics.

Age 6.12±4.72

Weight 22.45±16.34

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Table4 Statisticalanalysisofglottisviewscoreswithdifferentmaneuversin0---2yearsofagepatients(n=38).

Maneuver Score Neutral JTTP JTOM HTCL TA

Neutral(anterior) 2.79±1.01 1 0.04 0.02 0.00 0.00

JTTP(anterior) 2.32±0.87 0.04 1 NS 0.00 0.00

JTOM(anterior) 2.19±0.87 0.02 NS 1 0.007 0.00

HTCL(anterior) 1.40±0.50 0.00 0.00 0.007 1 NS

TA(anterior) 1.29±0.46 0.00 0.00 0.00 NS 1

Neutral(posterior) 2.29±0.77 1 0.039 0.008 0.00 0.00

JTTP(posterior) 1.95±0.70 0.039 1 NS 0.00 0.00

JTOM(posterior) 1.79±0.62 0.008 NS 1 0.002 0.00

HTCL(posterior) 1.37±0.54 0.00 0.00 0.002 1 NS

TA(posterior) 1.23±0.43 0.00 0.00 0.00 NS 1

Valuesaremean±standarddeviation.

JTTP,jawtrustwithteethprotrusion;JTOM,jawtrustwithopenedmouth;HTCL,headtiltchinlift;TA,tripleairwaymaneuver;NS, notsignificant(p>0.05).

JTTP(anterior) 2.00±0.73 0.005 1 NS 0.00 0.00

JTOM(anterior) 1.71±0.70 0.00 NS 1 0.007 0.00

HTCL(anterior) 1.31±0.47 0.00 0.00 0.007 1 NS

TA(anterior) 1.13±0.34 0.00 0.00 0.00 NS 1

JTTP(posterior) 1.78±0.58 0.026 1 0.048 0.00 0.00

JTOM(posterior) 1.53±0.56 0.00 0.048 1 0.03 0.00

HTCL(posterior) 1.26±0.45 0.00 0.00 0.03 1 0.034

TA(posterior) 1.08±0.27 0.00 0.00 0.00 0.034 1

JTTP,jawtrustwithteethprotrusion;JTOM,jawtrustwithopenedmouth;HTCL,headtiltchinlift;TA,tripleairwaymaneuver;NS, notsignificant(p>0.05).

resultedrespectively moreimprovementinposterior glot-tisview during FOB in 2---6 years of age group (p>0.05). Statistical analysis of the view of anterior and posterior laryngopharyngealtissuesshowedattheTables4---6.

In 0---2 years of age group; at anterior LP view scores

bothfourairwaysupportingmaneuvers(JTTP,JTOM,HTCL,

TA) clinically and statistically (p<0.05) improved

ante-rior and posterior laryngopharyngeal view via flexible

fiberopticbronchoscopywhencomparedwithneutral

posi-tion. Howeverthere were nosignificant differencefound

betweenJTTPandJTOMmaneuvers(p>0.05).HTCLandTA

maneuversshowedstatisticallysignificantdifferencewhen

JTTP(anterior) 2.00±0.83 0.015 1 NS 0.00 0.00

JTOM(anterior) 1.93±0.75 0.009 NS 1 0.00 0.00

HTCL(anterior) 1.22±0.42 0.00 0.00 0.00 1 NS

TA(anterior) 1.11±0.31 0.00 0.00 0.00 NS 1

JTTP(posterior) 1.76±0.60 0.01 1 NS 0.00 0.00

JTOM(posterior) 1.62±0.61 0.001 NS 1 0.00 0.00

HTCL(posterior) 1.13±0.34 0.00 0.00 0.00 1 NS

TA(posterior) 1.02±0.15 0.00 0.00 0.00 NS 1

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compared with both JTTP and JTOM (p<0.05) but there werenosignificantdifferencefoundbetweenHTCLandTA maneuvers(p>0.05).

In2---6yearsofagegroup;atanteriorLPscoresshowed similar results like general score. All airway maneuvers clinically and statistically improved at posterior LP view scores. In contrast with general results; JTTP and JTOM, HTCL andTA scoresshowed statisticallysignificant results respectively.

In 6---15 yearsof age group;statistical analysisof both anteriorandposteriorLPviewscoresweresimilarwith gen-eralresultsand0---2yearsofagegroup.

Discussion

Accordingtoour study,comparedtotheneutralposition, allairway-supportingmaneuvers(JTTP,JTOM,HTCLandTA) improved both anteriorand posterior view of glottis dur-ingFOBinallpediatricagegroups.The bestmaneuversto improvebothanteriorandposteriorglottisviewin allage groupsareHTCLandTA.

Flexible FOB via nasal approach under deep sedation or general anesthesia in pediatric group of patients is widely practicedtechnique. Duringdeep sedationor gen-eralanesthesia,loss orreductionof muscletonein upper laryngopharyngealstructuresresultsposteriordisplacement oftongue,softpalateandepiglottisisthemainreasonfor airwayobstructionandlimitedvisibilityduringFOB,asFOB relies onaclear airspacearound bronchoscope’stip.This studywasaimedtodeterminetheeffectsoffourdifferent airwaysupportingmaneuversonglottisviewandtofindthe bestpositionforpatient’sheadandneckforaclearairway duringFOB.

Durgaetal.4_showed_that_jaw _trust_combined_with

lin-gualtractionresultsaclearairwaypassagefororotracheal

fiberopticintubation.UnfortunatelyDurgaetal.foundthat

jawtrustorlingualtractionfailtoproducefullclearairway

whenusedalone.Liftingtheepiglottisfromposterior

pha-ryngealwallis themajorfactorfor improvingthe viewof

anteriorlaryngopharyngealstructures.Chengetal.5_showed

thatJTTP,JTOM,HTCLandTAimprovestheviewofanterior

laryngopharyngealtissuesrespectively.Ourfindingspartially

supportChengetal.study.Wefoundthatbothfour

maneu-versimprovedanteriorviewhoweverwedidn’t found any

differences between JTOM and JTTP and similarly there

were no difference found between HTCL and TA

maneu-versinourstudyexceptforposteriorglottisview2---6years

of age group. In Cheng et al. study as they used muscle

relaxantsandtheirpatientswerenotspontaneously

breath-ing their results were less improved compared with our

results.Differencebetweentheagegroupsintwostudiesis

anotherfactorforcomparison.InacrossoverstudyStacey

etal.3 _compared_direct_laryngoscopy_and_jaw_trust_to_aid

Fiberopticintubation.Theyfoundthatdirectlaryngoscopy

producedbetterclearairwaypassagewhencomparedwith

jawtrustmaneuver.Unfortunatelytheycomparedonlytwo

methodstoassesstheireffectsonFiberopticview.Itis possi-bletofinddifferentresultsifothermaneuversthatweused

werealsoemployedintheirstudy.Ourstudybasedon

spon-taneous ventilating patients and the depth of anesthesia

mightbeinadequateforlaryngoscopy. Deepsedationwith

propofolandketamineiscommonlyusedinclinicalpractice

fortheproposeofhypnosisandanalgesiaforpediatric

bron-choscopicprocedures.6_Our_findings_showed_that_the_major

factors,thathasinfluenceontheanteriordisplacementof

theepiglottisfrom posterior pharyngeal wallare anterior

movementofmandibulaandheadtiltpositioning.

Recent studyby Abramsonetal.7 _assessed _age_related

changes of the upper airway by 3-dimentional computed

tomography.Theyfoundthatupperairwayparameterssuch

asvolume,surfacearea,length,meancross-sectionalarea

were increased in concordance with the increase in age.

Howevertheywerefoundnodifferenceregardingtosexin

airwayparameters.Kimetal.8_found_that_there_were

pro-portionaldifferencebetweenchildrenolderthan12months

ofageandchildrenyoungerthan12monthsofageregarding

ultrasoundmeasurementsofsubglotticdiameterand

empir-icalformulaforendotrachealtubefitting.

Vialetetal.9_found_that_slight_head_extension_narrows_the

angledeltaandimprovesalignmentofthelineofvisionof

theglottisandlaryngealaxis.Thisdatasupportourfindings

that positions including head extension like HTCL and TA

arelikelytoimproveglottisviewweatherinbronchoscopy

orotherimagingmodalities.

Meieretal.10_showed_that_chin_lift_and_jaw_trust

maneu-vers combined with continuous positive airway pressure

(CPAP)improvetheglotticopeningviaflexiblenasal

laryn-goscopy and decrease stridor in spontaneously breathing,

anesthetizedchildren.HoweverBruppacheretal.11_showed

that jaw trust has a superior effect to improve airway

patencyandventilationin childrenundergoing

adenoidec-tomywhencomparedwithchinliftandCPAP.

Reberetal.12_investigated_Jaw_trust,_Chin_lift_and

com-binationofthismaneuverswithCPAPin24childrenhaving

adenotonsillar hypertrophy. Similarly with our study chin

liftcombinedwithCPAPshowedthemostefficient

combi-nationtoreduce thestridorandimprovetheglottisscore

whencomparedwithjawtrust aloneor combination with

CPAP.

In conclusion, airway-supporting maneuvers improves

glottisviewduringFOB.HeadtiltchinliftandTripleairway

maneuverswerefound tobethemost efficientmaneuver

forbothanteriorandposteriorglottisviewduringpediatric

Fiberopticbronchoscopy.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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